DOCTORAL PORTFOLIO IN COUNSELLING PSYCHOLOGY.

by

Sarah Mills, Bsc Psychology.

Thesis submitted in partial fulfilment of the requirements of the University of Wolverhampton for the post-graduate degree of:

Practitioner Doctorate in Counselling Psychology.

The following research has been conducted in line with the guidelines presented for the module: Doctoral Portfolio, PS5018.

October 2012.

1

Declaration.

The research dossier of any part thereof has not previously been in any form

to the University or to any other body whether for the purposes of

assessment, publication or for any other purpose (unless otherwise

indicated). I further confirm that the intellectual content of the work is the

result of my own efforts and no other person.

The right of Sarah Mills to be identified as author of this work is asserted in

the accordance with ss.77 and 78 of the Copyright, Designs and Patents Act

1988. At this date copyright is owned by the author.

Signed......................................

Date......................................

2

Contents. Pg No.

Word Count Summary..................................................................5

Acknowledgements......................................................................6

Preface to the Doctoral Portfolio………......................................9

Academic Dossier.......................................................................26

Should the role of identity change be addressed

in Post-traumatic Stress Disorder (PTSD)?........................27

Solution Focussed Therapy and Emotionally Focussed

Therapy: Comparing and Contrasting Two

Theoretical Approaches to Couple Therapy.......................45

Therapeutic Development Dossier..............................................62

Counselling Psychology in Practice...................................63

Reflective Essay: Professional Issues................................83

Research Dossier: Bridging the gap between treatment

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efficacy and effectiveness in Post-traumatic

Stress Disorder (PTSD)................................................................101

Preface to Research Dossier...............................................103

Critical Literature Review: Distinguishing between

treatment efficacy and effectiveness in Post-traumatic

Stress Disorder (PTSD): Implications for

contentious therapies..........................................................112

Research Report: How do veterans make sense of their

disengagement from traditional exposure therapy

and their subsequent engagement in a non-exposure

based intervention for Post-traumatic Stress Disorder

(PTSD)?: An Interpretative Phenomenological Analysis...131

Critical Appraisal of the Research Process.........................226

References......................................................................................235

Appendices.....................................................................................257

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Word Count Summary.

Section Word Count

Preface 3,767

Academic Dossier

Life Span Approach Essay

Couple Therapy Essay

3,000

3,200

Therapeutic Development Dossier

Supervised Practice Essay

Professional Issues Essay

4,366

4,297

Research Dossier

Search Strategy

Preface to the Research Dossier

Critical Literature Review

Research Report

Abstract

Introduction

Method

Results

Discussion

Conclusion

Critical Analysis

91

929

4,044

166

2,882

3,002

7,916

5,152

835

1717

TOTAL 45,364

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Acknowledgements.

I would like to thank all the people who have supported me throughout the

process of this research.

My first special thank you goes to my Director of Studies Dr Lee Hulbert-

Williams. I really could not have completed this research without your

continued support and guidance. You have always been there for me in my

time of need and have given me encouragement to have faith in my own

ability. Your commitment, not only to this research project, but to academic

research in general is truly inspirational. I am eternally grateful. Secondly,

thank you to Dr Nicky Hart for your Counselling Psychology contributions

and your support and advice, particularly in the latter stages of this research

project.

My second special thank you goes to my loving family. To my Mum and

Dad, you have always believed in my ability to succeed and have allowed

me, through your continued financial support, to follow my dreams. I hope

I have made you proud. To my wonderful fiancé Tom, I have sometimes

wondered how you have put up with me throughout the latter stages of this

research project. You are my best friend, confidant and my biggest

supporter. I could not have got through this course without your ever

present emotional support and light heartedness. Thank you for asking me

to be your wife! To my darling sister you, as ever, have been my emotional

outlet. Thank you for being infinitely encouraging and for understanding

what it is like to be under such academic pressure. I love you all.

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To my friends, thank you for your patience. I promise you will now get

Sarah back! To Rachael in particular, I would not have known what to do

without you in these last few months. You are truly a friend for life.

Last, but by no means least, a special thank you to the founder of Spectrum

Therapy and to the participants that agreed to take part in my study. Thank

you for sharing your experiences with me. I am indebted to you all.

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All work throughout this portfolio has been appropriately anonymised

and all identifiable information removed so no participant can be

identified.

Preface to the Doctoral Portfolio.

8

The following portfolio aims to document a selection of work completed for

the Practitioner Doctorate in Counselling Psychology course at the

University of Wolverhampton. The work outlined in this portfolio aims to

demonstrate my transition from an unconfident first year trainee who relied

on Cognitive Behavioural handbooks in order to “carry out” therapy to an

eclectic trainee that continually seeks to mould therapeutic treatment plans

to each individual client need. This process of change will be discussed in

the following preface with references made to the work included in the

doctoral portfolio.

The portfolio has been divided into three main sections: an Academic

Dossier, a Therapeutic Dossier and a Research Dossier. The Academic

Dossier contains two essays completed in year two and three of the Doctoral

programme. The first essay included in this Dossier was completed for the

Life Span module and the second, for the Couple Therapy module. The

Therapeutic Development Dossier contains a Supervised Practice essay

which explores my three years on placement as a trainee Counselling

Psychologist and a Professional Issues essay which reflects on all elements

of my three year training, documenting both my personal and professional

development throughout the course. Finally, the Research Dossier contains

a critical literature review, a qualitative research report and a critical

appraisal of the research process.

9

As a supplement to the Doctoral Portfolio there is a Confidential

Attachment, which contains a client study, a process report, raw data from

the research project i.e. transcripts, annual progress reviews of the research

process and feedback sheets for all work contained in the Portfolio and

Confidential Attachment. In line with the confidentiality rights of clients

and participants who have volunteered to be a part of this work, all

potentially identifying information has been altered to ensure anonymity.

Being a Counselling Psychologist in training has brought many challenges.

The most predominant challenge that I have been faced with over the three

year doctoral programme is the distinction between the “psychologist”

element of the course i.e. as a scientific professional and the “counselling”

element i.e. as a therapist that values meaning-making and validating a

client’s subjective experiences. This distinction was initially highlighted to

me when working in NHS settings that were often medically dominated and

where language such as “diagnosis” and “treatment” were commonplace.

Such a stance seemed to contradict my underlying philosophies as a

humanistic, existential practitioner.

In my first year placement I was working in a Primary Care setting that

relied heavily on the use of “diagnosis” to determine treatment plans.

Clients would enter into therapy with a referral letter that outlined the

client’s presenting symptoms and often there would be a recommendation

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made about what type of therapy should be used; more often than not, this

would be Cognitive Behavioural Therapy (CBT).

After I had worked with a few clients using a Cognitive-Behavioural

approach, I began to notice that the Humanistic approach I was learning in

my first year university lectures, did not feature at all in the therapies

offered to clients in my practical place of work. I began to get concerned

that my first year client study, which aimed to document my work with a

client using a Person-Centred approach, would not be possible. I spoke to

my supervisor about my concerns and she told me that the main model of

care offered to clients at the department was CBT because, as clinical and

counselling psychologists, we should be following the “scientist-

practitioner” model of care. However the department could make special

allowances for my university requirements.

Having engaged in both the counselling concepts and counselling skills

courses prior to enrolling onto the Doctorate in Counselling Psychology

course, I was already aware of the importance of Rogers (1963) core

conditions in therapy, but I was unsure how these concepts alone could

produce therapeutic change in my clients. I was eager to learn this. As

described in my Professional Issues essay, these were the very concepts that

attracted me to the Counselling Psychology profession. Owing to this, I was

disappointed to be informed that a “special allowance” would have to be

made for me to be able to practice these skills with a client. I thus began a

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quest to find out what the “scientist-practitioner” model was and why it was

apparently stopping me from practising my humanistic skills!

The scientist-practitioner model attempts to combine both the practical and

research elements of the profession by advocating that the treatment

methods with the highest levels of efficacy should be used in therapeutic

practice (Newnham & Page, 2010). This often means that the

successfulness of a treatment method is determined through outcome trials.

As is the case for the most common mental health problems in the United

Kingdom, i.e. depression, anxiety and post-traumatic stress disorder, to

name but a few, CBT is outlined as the recommended treatment method

owing to its proven efficacy from randomised control trials and meta-

analyses (e.g. Butler, Chapman, Forman & Beck, 2005). It is important to

note however that the research base for CBT has been challenged, mainly on

the grounds of transferability of findings from research into practice (see

Merrett & Easton, 2008).

My relationship with CBT has waxed and waned over the three-year

doctoral training programme. Consequential to my insecurities as a first

year trainee who had little experience of “live” therapy, I found CBT to be a

very comfortable way of working. It provided me with the security I needed

to feel confident in therapy as I could follow the recommended interventions

for different symptom presentations and adhere to the predefined

formulations for specific psychological difficulties. Clinician treatment

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manuals that provided descriptions of what to do in each session, with

guidance even on how to present the concepts of CBT to my clients (e.g.

Padesky & Greenberger, 1990; Padesky & Mooney, 1995) were particularly

useful at this early stage in my training.

In addition, in my first year placement, the majority of my clients seemed to

be responding well to CBT. For those clients who were fortunate enough to

be from privileged backgrounds, who had secure attachment styles and who

had been adequately educated, CBT seemed particularly beneficial. Whilst

this was the case, my knowledge of other psychological therapies and

theoretical concepts was growing through my university lectures. I started to

recognise the usefulness of certain Gestalt concepts such as the “split self”

and how the empty chair technique could be used to help marry the differing

parts of a client into one complete whole (Paivio & Greenberg, 1995). In

addition, I began to expand on my initial knowledge of Roger’s (1963) core

conditions and how developing a strong therapeutic relationship could be

therapeutic in its self. For me, these approaches seemed to be more

exploratory in nature than the directive cognitive-behavioural approach I

was used to and as such I felt they were more in-keeping my underlying

philosophy as a Counselling Psychologist in training.

As I began to recognise the potential benefits of other ways of working with

my clients, I started to become increasingly frustrated with my first year

placement’s reliance on the National Institute of Clinical Excellence

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guidelines (NICE, 2008) for the selection of “treatment”. Whilst I could

understand the importance of incorporating efficacious treatment methods in

to my practice I was starting to strive for some autonomy for both my

clients and me in the decision making process of therapy.

In addition to my own frustrations, I started to agree with the concerns

posited by Merrett & Easton (2008) who query what happens to those

clients who do not respond well, or dropout of CBT. For me, this concern

was generated through recognition that CBT interventions were not suitable

for all my clients. Some, for instance, found it difficult to engage in certain

CBT interventions (e.g. exposure or homework tasks) even though they

presented with the necessary symptoms to warrant use of such an approach.

Through the Life Span module of the course I wanted to document this

aforementioned dilemma in my assignment as I had previously worked with

a client who felt his sense of Self had been lost through a traumatic

experience he had encountered. When applying the recommended

exposure based techniques to this client, which in essence are based in

cognitive and behavioural paradigms (Foa & Kozak, 1986), I found he

became increasingly frustrated as he felt therapy was an unnecessarily

painful experience. He found the re-living aspect of treatment highly

distressing and he felt the process was not addressing his true problem; his

loss of identity.

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I took my concerns about my client’s suitability to exposure therapy to

supervision. When I was working with this client I still regarded myself to

be an inexperienced therapist. I therefore held a belief that all other

professionals knew better than I. This belief filtered into my first year

supervision sessions and as such I took what my supervisor said to be the

absolute truth. Later on in my training I started to recognise that such a

concept did not exist in psychology!

At this time, I believe I was in Level One of Stoltenberg’s (1981)

developmental model of supervision where the supervisee is dependent on

their supervisor for guidance. Owing to this, when in response to my

concerns, she questioned my client’s motivations for change; I was reluctant

to challenge her. I didn’t challenge my supervisor on this point in spite of

feeling that it might be the model of treatment, not my client’s motivations,

that was the problem. I believe this reluctance to challenge my supervisor

was due to my belief that she was the “expert”. In addition, I was

continually aware that she had the power to either pass or fail me and such, I

wanted to please her. Later on in my training, through personal therapy, I

realised that I, like so many of my clients, had fallen victim to cognitive

distortions, as I was predicting that my supervisor would fail me, if I

challenged her.

Through writing the essay for the Life Span module, where I reported on the

notable absence of identity change in PTSD treatment, I began to recognise

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the practical dilemmas faced by Counselling Psychologists who are

encouraged to routinely adopt “best” evidence-based practices into their

treatment methods with clients. From this experience I found myself

strongly agreeing with Garcia and colleagues (2011: p1) statement “our

most effective therapies are only as good as our clients ability to complete

them”.

Through recognition of this dilemma, I started to immerse myself in the

literature that discussed this notable gap between what is deemed

efficacious, as determined through research trials, and what is deemed

effective in everyday practice with clients. A particular commentary in the

literature on this topic began to catch my attention pertaining to this

recognised gap in the treatment of PTSD, particularly with veterans of war

where high dropout rates and missed appointment sessions were noted as

commonplace (Erbes, Curry & Leskela, 2009). I began associating the

points suggested for the reduced effectiveness of exposure therapy to my

previous client’s concerns of engaging in a treatment method that a) seemed

to be highly distressing (e.g. Wells & Sembi, 2004) and b) seemed to

conflict with his ideas of what needed to be addressed in therapy (e.g.

Hemsley, 2010).

My experiences of working with a client in therapy, who was reluctant to

engage in the recommended treatment method for PTSD, and my

subsequent literature searches into the distinction between efficacy and

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effectiveness in psychological therapy, drove the premise of my current

research project. I knew fairly on in the research process that I wanted to

honour my previous client’s subjective experience of therapy by assessing

other people’s experiences of such a therapy. This research question lent

itself to a qualitative enquiry. As I had never used or studied this

methodology in depth before, I was initially reluctant to adopt a qualitative

method for my doctoral research, not least because there seemed to be

limited information and guidance on how to carry out such an analysis.

This was markedly different from my experience of carrying out

quantitative methods through my undergraduate training, where copious

amounts of literature on how to conduct different statistical analyses were

available (see Field, 2009).

Although I had initial reservations of adopting a qualitative method for my

research, I wanted to challenge myself. Firstly, it was the method best

suited to my research question. Secondly, I thought it would allow me the

opportunity to start to marry the scientific and subjective elements of my

profession, something that I had been struggling with in my clinical

placement. Finally, I was starting to notice that I had developed a

dependency on following CBT manuals in my clinical work with clients. I

was doing this in spite of my growing recognition that I wanted to expand

my repertoire of clinical skills. I therefore decided in both research and

practice to attempt to drop these manuals in an effort to enhance my

learning and grow as an autonomous Counselling Psychologist in training.

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In practice, the metaphor of “dropping the manual” was represented through

my choice of second and third year placements, where the use of both

directive and non-directive therapies was encouraged. Initially, the thought

of applying new interventions with clients was daunting, particularly when

utilising therapies that encouraged a more “here and now” way of working.

Whilst I began to recognise the benefit of such interventions for some of my

clients, I felt reluctant to put this learning into practice. This reluctance was

due, in part, to the unpredictable nature of this style of working; I felt

uneasy at the thought of dealing with issues as and when they came up in

therapy. Through my Professional Issues essay, I reflect on this dilemma,

attributing my reservations to the challenges these new approaches would

bring to my initial ideas of what it meant to be an effective therapist; a

therapist who had all the answers.

Having all the answers for my clients was a sticking point in my

development. Whilst I knew I wanted to change this aspect of my work, not

least because I had experienced the benefits of feeling empowered through

my own personal therapy, I didn’t know how to go about this in my own

clinical work with clients. Through supervision I began to realise that it was

acceptable not to know the answer to my dilemma by witnessing how

comfortable my supervisor was in not being able to provide me with the

answer. If one were to accept the assimilation model of change (Stiles,

2001) I was internalising my supervisor’s model of coping with uncertainty.

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This insight allowed me to slowly become more comfortable within therapy

when I felt uncertain of the answers or what to do next. Indeed, I found that

this way of being seemed to reflect positively in clients as they too began to

respond to their own life challenges in such a way. For me, this seemed to

facilitate a more relaxed way of being in therapy and indeed in supervision.

I felt as though the pressure of having to be right all the time had been

reduced. I found this helped me move from stage one of Stoltenberg’s

model of supervision (1981) into stage two as I began to feel more equal to

my supervisor as we were both recognising and validating each other’s

recommendations. Entering into therapy with clients in a more relaxed state

encouraged me to be more flexible in my approach which in turn enabled

me to incorporate other ways of working into my clinical practice. Through

my supervised practice essay, I document this transition from a practitioner

who used only CBT, to an aspiring eclectic practitioner who strives to select

therapeutic models and concepts to suit the subjective formulations of my

clients.

My journey to becoming an eclectic therapist has, by no means, been a

linear one. Indeed I see my process of change throughout this transition as

being in keeping with a more fluid model of change, where relapse is

deemed part of the process (e.g. Prochaska & DiClemente, 1986). Through

personal therapy, I began to notice that these relapses often occurred when I

felt over-whelmed or confused by a client’s presentation. In such an

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instance I would revert back to my trusted CBT manual to give me “the

answer” on what to do next. By reflecting on each lapse within supervision

and personal therapy I began to understand how I could learn and grow from

what I initially deemed to be a step backwards. The adoption of such

learning proved useful in my third year placement in an Eating Disorders

service, where clients often put extreme pressure on themselves to change

quickly and in a linear fashion.

Another challenge I faced in my transition from being a one-model therapist

to an eclectic practitioner came from opponents of eclecticism who question

how and why certain therapeutic tools are chosen (see Cutts, 2011). When

reading this literature I started to doubt my own decision-making processes

within therapy. Should I rigidly and routinely refer to the NICE guidelines

of best practice when choosing interventions for example? If I don’t do this

would I be working un-ethically?

I began to address these questions through my Couples Essay in my third

year of training. When writing this essay I decided to compare and contrast

two approaches to couple therapy: Solution Focussed Couple Therapy

(SFCT) and Emotionally Focussed Couple Therapy (EFCT). In comparison

to EFCT, SFCT had not received the required level of support from research

trials to warrant its inclusion into treatment guidelines. This said it did have

notably positive anecdotal support from both clinicians and clients in

relation to its usefulness within therapy. From this essay I started to see that

20

both therapies had strengths and drawbacks pertaining to the subjective

needs of, in this case couples, regardless of whether or not they featured in

treatment guidelines. In conjunction with my experiences in clinical

practice where I have found the suitability of therapy to be matched to client

need instead of the symptoms they present with, this learning continues to

drive my enthusiasm for working in an eclectic way with my clients. I

believe therapy preferences should be considered from an evidence base but

not at the neglect of valuing individual differences.

This learning connects to my underlying philosophies as a Counselling

Psychologist who holds the subjective needs of my clients in high regard.

This learning does not mean I advocate the abolition of treatment

guidelines. Indeed as Fairfax (2008: p32) highlights “there does of course

need to be evaluation, development and regulation of interventions”. What I

do stand to contest however, like many other professionals (e.g. Richardson,

2006; Newnes, 2007) is that solely awarding merit to therapies that perform

best in RCTs may limit our development and growth as a profession. This

point is very much a feature of my research where I aim to address the

notable gap between efficacy and effectiveness in the treatment of PTSD,

where the most efficacious treatment is not always adhered to in real-world

practice.

Through the course of the Doctoral programme I have had the opportunity

to work with a range of clients presenting with a number of different

21

problems, in a number of different clinical settings. This experience,

teamed with my academic studies has seen me move from an unconfident

first year trainee who relied on one therapeutic approach, to a reflective

practitioner who strives to mould therapeutic plans to suit the wants and

needs of my clients. Whilst I believe this forms the crux of my identity as a

Counselling Psychologist, I do recognise that certain clinical settings and

professional guidelines may challenge this way of working. Through

experience I have recognised that the balance between client-need and

service-need are often at odds and as such the freedom to be flexible in

therapy is often not possible. Whilst I foresee this as being a continued

dilemma for me, I am recognising that I feel comfortable not having the

answer.

References.

Butler, A.C., Chapman, J.E., Forman, E.M., & Beck, A.T. (2005). The

empirical Status of Cognitive Behavioural Therapy: A review of meta-

analyses. Clinical Psychology Review, 26, 17-31.

Cutts, L. (2011). Integration in Counselling Psychology: To what purpose?

Counselling Psychology Review, 26 (2), 38-48.

22

Erbes, C.R., Curry, K.T., & Leskela, J. (2009). Treatment Presentation and

Adherence of Iraq/Afghanistan Era Veterans in Outpatient Care for

Posttraumatic Stress Disorder. Psychological Services, 6 (3), 175-183.

Fairfax, H. (2008). “CBT or not CBT” is that really the question? Re-

considering the evidence base – the contribution of process research.

Counselling Psychology Review, 23 (4), 27-37.

Field, A. (2009). Discovering Statistics Using SPSS. (3rd Ed). London:

Sage.

Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: Exposure

to corrective information. Psychological Bulletin, 99(1), 20-35.

Garcia, H.A., Kelley, L.P., Rentz, T.O., & Lee, S. (2011). PreTreatment

Predictors of Dropout From Cognitive Behavioural Therapy for PTSD in

Iraq and Afghanistan War Veterans. Psychological Service, 8 (1), 1-11.

Hemsley, C. (2010). Why this trauma and why now? The contribution that

psychodynamic theory can make to the understanding of post-traumatic

stress disorder. Counselling Psychology Review, 25(2), 13-20.

Merrett, C., & Easton, S. (2008). The Cognitive Behavioural Approach:

CBT’s Big Brother. Counselling Psychology Review, 23 (1), 22-33.

National Institute for Health and Clinical Excellence Guidelines (NICE).

(2008). Commissioning Guide: Implementing NICE guidance. Available

[Online]:

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http://www.nice.org.uk/media/DD8/F2/CBTCommissioningGuide.pdf .

Retrieved: 22/04/2012.

Newnes, C. (2007). The implausibility of researching and regulating

psychotherapy. Psychotherapy Section Review, 28-38.

Newnham, E.A., & Page, A.C. (2010). Bridging the gap between best

evidence and best practice in mental health. Clinical Psychology Review,

30, 127-142.

Padesky, C., & Greenberger, D. (1995). Clinican’s Guide to Mind Over

Mood. New York: Guildford Press.

Padesky, C., & Mooney, K.A. (1990). Presenting the Cognitive Model to

Clients. Available [Online]: www.padesky.com/clinicalcorner/pdf.

Retrieved: 02.02.12.

Paivio, S., & Greenberg, L.S. (1995). Resolving unfinished business:

Experiential therapy using empty chair dialogue. Journal of Consulting and

Clinical Psychology, 63, 419-425.

Prochaska, J.O., & DiClemente, C, C. (1986). The transtheortical approach.

In J. Norcross (Ed), Handbook of Eclectic Psychotherapy. New York:

Brunner/Mazel.

Richardson, P. (2006). The Layard Proposals, a brief overview.

Psychotherapy Section Review, 41, 23-27.

Rogers, C. (1963). The concept of the fully functioning person.

Psychotherapy, 1 (1), 17-26.

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Stiles, W.B. (2001). Assimilation of problematic experiences.

Psychotherapy; Theory, Research, Practice and Training, 38 (4), 462-465.

Stoltenberg, C. (1981). Approaching Supervision from a developmental

perspective: The counsellor complexity model. Journal of Counselling

Psychologists, 28, 59-65.

Wells, A., & Sembi, S. (2004). Metacognitive Therapy for PTSD: A Core

Treatment Manual. Cognitive and Behavioural Practice, 11, 365-377.

25

ACADEMIC DOSSIER

26

Should the role of identity change be addressed in post-traumatic stress disorder (PTSD)?

Identity.

Our understanding of identity and its role in determining behaviour has

come a long way since it was first given significant attention by Erikson in

1956 (Kroger, 2007). Erikson (1956) first recognised the presence of what

he termed an “ego identity” through his work with World War II veterans.

He argued that, held at the heart of the veterans’ psychological disturbances,

was a unified loss of the self in terms of behavioural predictability and self-

continuity. Developmentally, Erikson (1963) contributed to lifespan theories

with his eight stage life cycle scheme through which he pronounced identity

as being a static concept. He argued that identity crises typically begin in

adolescence and are either resolved, or not resolved by early adulthood, a

process he termed “role confusion”.

Erikson’s (1956) work on identity became the building blocks for future

research and debate surrounding the concept of identity. Research since has

identified cultural variations in identity formation with differences between

westernised and non-westernised ideas of successful identity formations

addressed (Tobin, Wu & Davidson 1998) and differing ideas surrounding

the origins of identity offered, with Baumeister’s (1987) socially

27

constructed identity model and Kroger’s (1996) bio-psycho-social model of

identity formation. Whilst there is ongoing debate in the area of identity, it

would seem that agreement has been made surrounding the fluidity of

identity development. Once seen as a static concept (Erikson, 1963),

identity is now viewed as more dynamic and influenced by changing life

events (McAdams, 1993).

Is it static?

The idea that identity is static has been refuted by work looking into identity

change. Marcia (1966) looked at identity classification in a more qualitative

way than previously done with her proposal that identity development

comprises four different identity statuses namely, foreclosure, identity

achievement, identity diffusion and moratorium (Anthis & LaVoie, 2006).

Marcia’s model sees identity as constantly changing throughout the lifespan,

giving us a feel of identity being more fluid. Although her model is able to

encapsulate identity change, it has been criticised for being more descriptive

than explanatory in nature as it does not suggest reasons for a change

(Kroger, 2007). In order to determine any precursors to identity change we

need to refer to later research into identity and trauma.

Trauma, Identity and Treatment.

28

As Erikson (1963) highlighted, a feeling of knowing who we are provides us

with direction, continuity and a sense of predictability in an ever-changing

world. For many, experiencing a trauma can tear apart their previous

understanding of themselves and the world (Janoff-Bulman, 2006). It has

therefore been suggested that psychological stability following a trauma is

successfully achieved through the development of a renewed sense of self

(Neimeyer, 2006). This can be seen in people navigating their way through

a serious illness.

It is not uncommon for people who are suffering with, or have suffered

from, a major illness to feel differently about themselves (Luyckx et al.,

2008). Indeed Davidson and Roe (2007) suggest the major challenge of

overcoming a serious illness, whether it be physical or mental is to

overcome the ‘‘loss of valued social roles and identity, isolation, loss of

sense of self and purpose in life’’. It has been suggested that people who

compare themselves negatively to others with regard to their situations and

the situations of their peers may experience the negative effects of an illness

for longer than people who do not (Carless & Douglas, 2008). A feeling of

a loss of self can also bring with it a sense of grief, as the individual mourns

the loss of their previous self identity (Repper & Perkins, 2003).

Not all individuals who experience a major illness report a negative shift in

their sense of identity. Research has started to document Post-Traumatic

Growth (PTG) in individuals who have suffered with cancer for example

29

(Abernathy, 2008). It is thought that a positive outcome is due to an identity

shift which is one of power and strength rather than of weakness or illness.

In breast cancer patients the term “survivorship” has been documented as a

collectively held identity status in people who have overcome the disease

(Kaiser, 2008).

Work into trauma and abuse has also given us an insight into the role of

identity change on psychological wellbeing. Recent research into this area

is starting to move away from the traditional view that the trauma itself

causes psychological problems (Robins, 1978) as studies on the effects of

early abuse and attachment styles are starting to recognise the presence of

individual differences in interpretation of the abuse and later psychosocial

difficulties (McCarthy & Maughan, 2010).

The National Institute for Clinical Excellence (NICE, 2008) guidelines do

not specify any one recommended treatment method for client’s presenting

with trauma. Therapists therefore are allowed freedom to construct the

therapeutic plan in terms of what is best suited for individual clients. In

therapy settings, counselling psychologists work with trauma in a number of

ways. Trauma can present itself alongside other clinical disorders as seen

with client’s presenting with illness or abuse as highlighted above, or it can

be the central aspect of a client’s problem as seen in post-traumatic stress

disorder (PTSD).

30

Identity, Post-traumatic stress disorder and Treatment.

Post-traumatic stress disorder (PTSD) was recognised as a standalone

disorder in 1980 by the Diagnostic and Statistics Manual IV for Mental

Health (DSM-IV). The DSM-IV classifies the disorder in terms of criteria

clusters. Criterion A states that the disorder may develop following a

stressful event where an individual is confronted with death, threat of death,

serious physical injury or threat to physical integrity. Criterion B highlights

the symptom of re-experiencing the traumatic event, more commonly

known as flashbacks. Criterion C refers to the avoidance of reminders to

the trauma and Criterion D to hyper arousal including exaggerated startle

responses and irritability (NICE Guidelines, 2008).  

Current treatment guidelines recommend that trauma focused psychological

therapy, in particular Cognitive Behavioural Therapy (CBT) or Eye

Movement Desensitisation Reprocessing (EMDR), should be offered to all

patients presenting with PTSD (NICE Guidelines, 2008). Exposure therapy

requires clients to vividly recount the traumatic event that caused them fear,

threat of death or serious physical injury. Clients are repeatedly asked to

confront the memory of the event until their emotional responses decrease

and they can be gradually introduced to fear evoking stimuli (Schnurr et al.,

2007). Although the effectiveness of this treatment method has been proven

31

(Elhers et al., 2010), it has faced criticism over recent years for being too

ridged (Feeney, Hembree & Zoellner, 2003) and thus losing the essence of

the person in the process (Hemsley, 2010). In order to explore this point, it

seems preferable to refer to a case vignette from my own clinical practice:

Tom (pseudonym) is a 31 year old male who was involved in a fatal car

accident of which he was later charged and convicted of manslaughter

(Criterion A). In the period between the accident and the trial Tom started

experiencing flashbacks of the event (Criterion B). He was unable to pass

by the scene of the crime and was unable to be a passenger in a motor

vehicle (Criterion C). Prior to the incident Tom considered himself to be a

respectable member of his community with many friends. He had a job, and

although he was still living with his parents, he had plans to start renting

his own flat. After the event Tom became introverted and was experiencing

trouble sleeping (Criterion D). He believed himself to be a “murderer” and

thought that others would view him as one also. He had lost all hope for the

future as he felt unworthy of one.

In supervision it was decided that I would treat Tom for PTSD as he

presented with all the symptoms of the disorder. The treatment plan was

devised in accordance with the NICE guidelines (2008), which states that

exposure therapy should be offered to all clients presenting with PTSD

under the premise that the development of symptoms derives from the

individual’s inability to process the experience adequately.

After a couple of sessions with Tom it became evident that his problems

were not centred around the flashbacks, although these were causing him

32

distress, but were mainly directed towards his own loss of self. He felt

unable to connect with himself or others in a positive way and so was

avoiding the outside world. He was confused over his reaction to the event

as prior to this he saw himself as a strong person and now he felt weak and

unable to cope.

Tom was sentenced before therapy could be completed. No work was

carried out to address his identity shift as it was thought best to follow the

instruction from NICE (2008). Therefore some brief exposure work had

been carried out to try and piece together the sequence of events from the

accident. Tom reported feeling no better at the end of therapy than he did

at the beginning.

When looking at the work surrounding trauma and identity one of the major

considerations seem to be on the subjective nature of identity change

(Mathieson & Stam, 1995). This would appear not to be the case for the

treatment of PTSD. In fact, as Hemsley (2010) argues it seems to encourage

the exact opposite, stating that “the structure of exposure therapy can often

discourage reflection upon the individual’s meaning of the experience as we

as therapists move away from a reflective form of practice into a more

medical one”.

The case example above is presented in an effort to support the ideas

presented by Hemsley (2010). Referring to Tom it may have been more

relevant to work with him in terms of his new felt sense and to reflect upon

the similarities or differences he felt since the accident in terms of his

identity. This is not to undermine the usefulness of a structured Cognitive

33

Behavioural approach in PTSD treatment. Work by Schnurr and colleagues

(e.g. 2007) have highlighted the value of addressing the symptoms of PTSD

in treatment, however concerns are raised around the static formulations and

the recommended treatment methods presented by NICE (2008) for PTSD

in terms of identity loss following trauma.

Debate surrounding the usefulness of formulations to clients in therapy is

ongoing (Johnstone & Dallos, 2006). Therapists can often be directed by

pre-determined formulations, especially in CBT (Herbert & Wetmore,

1999). Whilst it is argued that formulations are good for providing a

guideline to treatment (Herbert & Wetmore, 1999), do they allow for

therapists to lose the essence of the client in their description? In terms of

Tom, it was felt that the pre-designed formulation (Herbert & Wetmore,

1999) and the recommended treatment guidelines for PTSD as presented by

NICE (2008) made the treatment plan feel rigid with no allowance for

individual differences in treatment. In fact NICE (2008) have faced

criticism for this by some professionals previously, as they have been asked

the question “do all clients with PTSD present with the same symptoms”

(Hemsley, 2010)? From the case vignette, it would appear that although the

symptoms of PTSD were present in Tom’s presenting problems, the role of

identity change was possibly more important to address in his treatment.

Identity is considered to be a subjective concept (Abernathy, 2008). It is the

individual’s view of the self which provides direction and consistency in an

ever changing world (Erikson, 1963). With the evidence of research arguing

that identity change is a required component of successfully navigating

34

through a trauma (Neimeyer, 2006), are we right to be ignoring it in our

treatment methods for PTSD? It is suggested that by incorporating the

concept of identity change into the treatment methods for PTSD we could

help the intervention move away from what Hemsley (2010) terms the

“medical model of PTSD treatment” by allowing for more idiosyncratic

variances that better suit the underpinning philosophy of counselling

psychology.

With regard to exposure therapy, concerns are also raised around its

suitability for all clients’ suffering with PTSD. Dropout rates for this type

of treatment are seen to be high (Bradley, Greene, Russ, Dutra and Western,

2005) and it is even thought by some to be damaging to some client groups

(Steenkamp et al., 2010). Specifically, research into children has

documented how this type of treatment could be particularly harmful for

young clients’ as it could lead to them being re-traumatised (White, 2005).

Narrative therapy, as a treatment for PTSD, has proven to be particularly

useful with this age group. White (2005) argues that the effectiveness of

narrative therapy is down to it’s emphasis on the different identity statuses

a child can poses both before, during and after the traumatic event (White,

2005). It is believed that this type of therapy is useful because it helps

rebuild the individual’s shattered sense of identity following a trauma

(Crossley, 2000).

From these insights into Narrative Therapy it is suggested that this type of

treatment might also be useful when working with client’s in the adolescent

35

or early adulthood phase of life. Adolescence is a time regarded by

psychologists as the critical period for self and identity development

(Marcia, 1966). It is known as a time of self-discovery, uncertainty and a

period through which individuals are finding their way in the world (Tanti,

Stukas, Halloran & Foddy, 2010). The effects of trauma in this crucial

phase of identity development have been documented. Carrion and Steiner

(2000) found a link between delinquent behaviours and a dissociated

identity status in adolescents who had experienced trauma. Also, with the

understanding that identity is not a mysterious entity but rather a cohesive

result of a person’s life (Gergen & Gergen, 1988) it is plausible that a

trauma experienced at this time could have profound effects on the

individual at the level of identity and thus may need to be addressed in

treatment.

Critics of exposure therapy document that this type of treatment is too rigid

(Feeney, Hembree & Zoellner, 2003), and not suitable for all PTSD

sufferers (Bradley, Greene, Russ, Dutra & Western, 2005). From the

research it would appear that different forms of treatment maybe more

suited to clients of different ages as shown through work into narrative

therapy (White, 2005). For children and adolescents particularly, it is

suggested that treatment methods that look to work on identity change

following a trauma may be particularly relevant as these individuals are

navigating their way through what psychologists term “the crucial stage of

identity development” (Tanti et al., 2010). It is therefore put to question

36

whether or not we are right to have only one form of therapy documented by

NICE (2008) for the treatment of PTSD for all clients.

Identity and Risk factors in Post-Traumatic Stress Disorder.

As well as having implications for treatment, the concept of identity change

following a trauma could also help develop our understanding of why some

people develop PTSD and others do not. Although this suggestion was

rather frowned upon in earlier work into PTSD as the very question seemed

to imply blame on the part of the victim (Blank, 1985), psychologists

nowadays are starting to recognise the importance of identifying pre-

disposing risk factors to PTSD development (McNally, 2010). Vulnerability

factors such as the severity of the trauma, a pre-psychotic diagnosis and a

lack of social support have been highlighted as having an influence on

PTSD development (McNally, 2010). It is argued that identity change could

also be added to this list if we refer to the work carried out by Janoff-

Bulman (2006) on trauma victims.

Janoff-Bulman (2006) found that victims of trauma only experienced

psychological problems if they viewed the event to be traumatic. This

suggests that the event itself is not traumatic but rather that “trauma” is

defined by the individual’s perception of the event. Indeed, Thoits (2003)

argues that psychological distress following a trauma occurs when the

actions of oneself and or others do not match the individual beliefs of how

one or others should act. Drawing on from this, could it be that PTSD

develops when the traumatic event clashes with how one believes they or

others should behave? For instance could problems occur at the level of

37

identity whereby a rape victim who once viewed themselves as being

strong, now believed they were weak and vulnerable? If we look at work

into illness and identity it would suggest so.

When looking at the research surrounding cancer sufferers, psychologically

positive outcomes have been found to be determined by the person’s

identity shift from a status of weakness to a feeling of power or strength

(Kaiser, 2008). Could it also be argued therefore that a negative identity

shift in individuals presenting with PTSD could actually pre-determine the

vulnerability of the individual to the disorder? It is suggested that future

empirical examinations into the effects of identity change on pre-disposing

risk factors in PTSD development need to be addressed.

Conclusion.

The points made surrounding identity in terms of risk factors, the treatment

methods for the disorder in differing age groups and static formulations pre-

designed for the treatment of PTSD (Herbert & Wetmore, 1999) have

obvious implications for psychologists in therapy settings. It has been

argued that by incorporating the subjective concept of identity change into

treatment methods for PTSD we could help it move away from what some

psychologists are terming the “medical model of PTSD treatment”

(Hemsley, 2010). Work into PTSD treatment with children has also offered

insights into the effectiveness of other forms of treatment, namely Narrative

Therapy, in reducing the symptoms of PTSD in children (White, 2005).

Implications from this research have been discussed in terms of adolescents

and raised concerns over the NICE guidelines (2008) suggestion that there is

38

only one effective form of treatment in reducing the symptoms of PTSD in

all sufferers.

Overall it would seem that the concept of identity change in PTSD should,

at the very least, be considered in terms of treatment for PTSD in differing

age groups and in determining risk factors for the disorder.

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44

Solution Focussed Therapy and Emotionally Focussed Therapy:

Comparing and Contrasting Two Theoretical Approaches to Couple

Therapy.

Introduction.

Couple therapy has evolved considerably since its inception in the early

1930’s. It has moved from being almost universally influenced by

psychoanalytic theories and practices through to the more modern

influences of cognitive-behavioural and emotionally-focused, attachment

style theories and concepts (Gurman, 2008). This growth has mainly been

in response to the increasing demand of such a therapy as relationship

difficulties have become more widely acknowledged and help for dyadic

problems increasingly sought after (Boddington & Lavender, 1995).

Recently, and in response to this increased demand, considerable attention

has been given to the development of psychologically efficacious and

theoretically sound treatment modalities that can be integrated into a

therapists’ practice with couples (Scaturo, 2002).

The current assignment aims to explore the possible benefits and drawbacks

of two separate approaches to couple therapy: Solution-Focused Therapy

and Emotionally-Focused Therapy. These two approaches were chosen

because they both adopt a non-pathological stance (Fernando, 2007; &

Johnson, 2004), a principle which sits well with the underlying philosophy

45

of counselling psychology (Fairfax, 2008) and they both are relatively new

approaches to treatment, when compared to psychoanalytic or behavioural

movements. This said the two approaches differ considerably in terms of

therapeutic focus and therapeutic intervention. Both solution-focused and

emotionally focused couple therapy will be compared and contrasted with

one another through the exploration of an illustrative case vignette. This

case vignette refers to a couple, whom for the purpose of the assignment,

will be named Susan and Jonathan (pseudonyms). It is important to use

pseudonyms when presenting client work in an assignment as it helps

protect client confidentiality (BPS, 2009).

For a full description of Susan and Jonathan’s presenting problem and

history, please refer to Appendix 1.

Solution-Focused Couple Therapy and Emotionally Focused Couple

Therapy: An Overview.

Solution-Focused Couple Therapy (SFCT) is a relatively new, time-limited

therapeutic approach to therapy, which was founded by Shazer & Berg in

the early 1980’s (Gurman, 2008). SFCT is gaining momentum in both

research and practice due to the positive anecdotal reports from both client

and therapist in relation to its usefulness and with the increasing empirical

support it is receiving (Gingerich & Eisengart, 2000). Similar to SFCT,

Emotionally Focused Couples Therapy (EFCT) is a relatively new

46

theoretical approach to treatment developed by Johnson and Greenberg in

the early 1980’s (Johnson, 2004). EFCT, along with Behavioural Marital

Therapy (BMT), is recognised as being an efficacious treatment method for

couple therapy as determined through clinical trials (Jacobson & Addis,

1993). Such recognition is not yet applied to SFCT as it has not received

the same level of empirical attention as the aforementioned therapies

(Gingerich & Eisengart, 2000).

The focus of SFCT, and perhaps one of its most defining features, relates to

its emphasis on the facilitative nature of therapy where couples can generate

solutions rather than discuss problems and resolve relational difficulties

(Trepper et al., 2008). Little attention is therefore placed on history taking

or on explorations of emotions attached to the problem itself (Gingerich &

Eisengart, 2000). In SFCT, the therapist is encouraged to use specific

techniques which aim to make the couple generate solutions themselves.

These techniques include the “miracle question” or “scaling questions”

which are used to decipher what solutions can be generated from the

problem or to search for part of the solution that may already be happening

(Hoyt, 2008).

In contrast to this, EFCT sees the primary enforcer of change to be an

individual’s relationship with their and their partner’s emotions (Johnson,

2004). With this is in mind, one of the predominant features of EFCT is the

therapist’s ability to guide the couple away from their present negative or

47

rigid responses towards their spouse, to a more flexible, sensitive way of

responding (Greenberg, 2004). The therapy therefore helps the couple

redefine how they see each other in the here and now through a greater

understanding of each of their emotional, internal worlds. This aspect of the

therapy is notably different to SFCT techniques which focus on the present

and the future solutions to a problem (Hoyt, 2008).

Whilst there are notable differences between the therapies in terms of

therapeutic focus, similarities can be made at the level of their underlying

philosophies as both therapies believe in the subjective nature of therapy

and both place the therapist, not as the expert, but as a facilitator of change

(Trepper, 2008., & Johnson, 2004).

Formulating the problems presented by the case vignette.

Considering that the focus of SFCT is on generating solutions to a problem

rather than focusing on the problem itself, the SFCT assessment is often

centred around who or what is important to the couple and what they would

like from their relationship in the future (Zimmerman, Prest & Wetzel,

1997). Owing to this focus, therapeutic formulations are developed to

provide a brief outline of the current maintenance cycles fuelling the

couple’s problems but are used more as a platform from which goals can be

set and client-led solutions generated (Trepper et al., 2008).

48

If we were to apply the concepts behind solution-focused couple therapy to

the case of Susan and Jonathan, one could formulate that, for Susan, having

regular contact with Jonathan has become increasingly important since their

youngest son Stephen has gone to university. Owing to this, she is starting

to place pressures on her Husband to find a new job closer to home.

Currently this pressure to be closer to home is causing Jonathan some

conflict as shown through the example given when he shouted “I can’t win”

and subsequently “went to the pub”. This reaction on Jonathan’s part is in

conflict with Susan’s desire to spend more time together.

In contrast to this SFCT explanation, the emphasis within an EFCT

framework is on the exploration and transformation of maladaptive

emotions through a process of awareness, acceptance and understanding

(Greenberg, 2004). Derived from the concepts that underpin attachment

theory, EFCT focuses on the attachment needs and fears of the couple in

determining maladaptive patterns of interaction (Ells, 2007).

With this in mind, the difficulties faced by Susan and Jonathan, could be

explained from an emotionally focused perspective in terms of their

attachment needs and subsequent emotional responses to their current

situations. Susan, for instance, appears to be responding anxiously to being

at home alone. This emotional response suggests a dependent attachment

style which is further supported by her over reliance on her youngest son

Stephen before he went to university. As Stephen has now moved out of the

49

family home, and since her mother has passed away, Susan is now seeking

intimacy and attention from her Husband. Jonathan, on the other hand,

appears to be detached from intimacy, preferring to be on his own. This

attachment style seems to have developed from his long stays in hospital

when he was younger and has since been perpetuated by his absence in the

family home owing to work commitments. The now current pull of

attention and intimacy from Susan is conflicting with Jonathan’s attachment

style and in response he appears to be in conflict. This is making Susan feel

further isolated and anxious, resulting in her issuing Jonathan with an

ultimatum.

The strengths and drawbacks of both therapeutic models when applied

to the case vignette.

One of the main challenges faced by a couples’ therapist is to get an

overview of the couple’s difficulties from both partners perspective

(Symonds & Horvath, 2004). With regard to the case above, there appears

to be a lot of information from Susan’s point of view about the difficulties

faced in her relationship with Jonathan. From her perspective there seems

to be a very clear reason for their current difficulties: the fact that Jonathan

works away from home. Conversely, there is only a small amount of

information provided which allows insight into how Jonathan maybe feeling

about the situation, alluding to his response to Susan’s ultimatum when he

threw his hands up, saying “I can’t win”.

50

From an SFCT approach, the focus of generating solutions to the problem,

rather than focusing on the problem itself, might be beneficial in the case of

Susan and Jonathan as it could help highlight the resources and abilities the

couple have in overcoming their difficulties rather than focusing on the

nature and development of the problem, techniques usually deployed in the

more traditional approaches to therapy (Tashiro & Frazier, 2007). This

solution focused approach might be particularly beneficial for Susan as it

feels as though she is currently overwhelmed by the problems faced in her

relationship, so much so, that she has felt the need to issue Jonathan with an

ultimatum. Such an ultimatum gives the reader the impression that Susan

may be entering into therapy with a negative view of their relationship.

Owing to this, it may be important that therapy, from the outset,

concentrates the couple’s attention on their desired future together rather

than on their past problems or current conflicts (Trepper et al., 2008). This

in turn might give Susan a different focus, shifting her attention away from

the negatives of what Jonathan isn’t doing to the positive aspects of what he

is doing.

Literature has supported the idea posted by SFCT that developing a positive

climate between clients can influence change and thus resolve issues.

Gottman, Swanson and Swanson (2002) suggest that if the therapeutic

process starts by discussing a couple’s positive attributes and the adaptive

ways they have previously overcome difficulties, they are more likely to use

this as a directive way of responding to their current difficulties. I feel that

for Susan and Jonathan, this move from a negative climate of response to a

51

positive one maybe helpful in drawing out the reasons for why they “both

want to stay together”. In order for a positive climate to be achieved, the

solution-focused therapist would adopt a “language of change” (Hoyt, 2008)

that focuses the couple on their combined goals of therapy and channels in

on their resources as a couple to solve their own problems. In light of this, I

feel that it might be important to ask Susan if there have been any times

when she hasn’t found the separation from Jonathan hard, to help her

generate any exceptions to the problem of Jonathan not being at home. In

addition, it would be useful for the solution focused therapist to draw on any

past examples where Susan and Jonathan have overcome adversity to help

highlight their ability as a couple to deal with their problems. In this

example, solution focused therapy might offer some advantages to those

therapies that, from the outset, aim to understand the often negative affect

caused by a couples current difficulties.

On the surface, it would seem that generating solutions to a problem, rather

than focusing solely on the problem itself is an effective, practical approach

to therapy. A statement which is supported by some of the positive outcome

literature on the success of solution focused therapy (see Zimmerman, Prest

& Wetzel, 1997). Whilst this is the case, some concerns are raised about

this type of approach when applied to couple therapy as it can fail to

acknowledge the role of emotion in a dyadic relationship (Kiser, Piercy &

Lipchik, 1993). Indeed emotionally focused theorists have criticised

solution focused perspectives on this basis as it “can discount a client’s pain

and suffering by focusing on exceptions to their problems only” (Johnson,

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2004). When applying this argument to the case vignette, one could

surmise that for Susan, not talking about her emotions in therapy could

become quite frustrating. An idea supported by the recognition that she

“expresses all the feeling in the therapy sessions” and that she feels

“isolated” from Jonathan. Unlike SFCT, EFCT would place high

importance on the emotional expression of a couple in the hope that it would

create a more secure bond between the two partners (Tashiro & Frazier,

2007).

From an EFCT standpoint, if Susan is feeling isolated and rejected by

Jonathan, I feel it might be important for him to hear this as it could help

reduce his negative response of frustration that he can’t seem to do anything

right. Conversely, if Jonathan is feeling overly challenged by Susan as she

strives for more intimacy, it might be worthy for Susan to hear this in light

of Jonathan’s history where he describes himself as “always a loner”. This

might help the feeling of rejection that Susan feels when Jonathan responds

to her demands by “going to the pub”. In this case, it seems important to

address Susan’s feelings of rejection as she is the one issuing Jonathan with

an ultimatum. In this regard, it would seem that EFCT would offer some

advantages over a solution-focused approach to treatment as literature on

the success of couple therapy has identified the importance of making the

rejected partner feel that they are still cared for by their significant other

(Carr, 2009).

53

Whilst it is suggested that the emotional expression of a couple can help

facilitate change and a hypothesis provided for how this type of approach

may help the couple in the case vignette, I feel that this type of therapeutic

approach might prove difficult for Jonathan. This feeling is generated by

the fact that he “has to be encouraged to talk at all in therapy”. Without

wanting to stereotype Jonathan into the traditional male category of not

being able to talk about his feelings, he may very well find emotional

expression difficult. Indeed research has looked at the consequences of the

socialisation of emotional expression, in westernised males in terms of their

difficulties in describing and accessing their emotional experiences (Fisher

& Good, 1997). In regard to this, similar traits have been reported in men,

to those found in Alexithymic sufferers, who struggle to access their

feelings because of a strong cognitive style that is concrete and reality based

(Levant et al., 2003). With this in mind, a more solution focused, practical

approach to therapy might be more suited to those client’s who struggle to

access their emotions as they would not have to describe their negative

affect, because the therapy would be based in a more concrete world of

solution-based answers.

Emotionally focused theorists have recognised this dilemma in their therapy

(see Johnson, 2004) and have alluded to a strong therapeutic allegiance

between therapist and client as helping those individuals who find emotional

expression difficult (Johnson, 2004). It is thought that if a therapist can

generate a strong allegiance with both partners and, if the partners can

generate a strong allegiance between themselves, therapy is more likely to

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be an open, safe place from which emotions can be expressed (Greenberg,

2004). This said I feel it naive to think that in real word practice this strong

allegiance could be developed and maintained between every therapist with

every couple. Gender disparities are noted in the literature as having a

bearing on the development of an allegiance for instance as has the context

of a couple’s dispute (Symonds & Horvath, 2004). Reflecting on this

dilemma, I also feel that the extent to which a couple blame each other for

their current difficulties could also be a barrier in developing a therapist-

client, client-client allegiance, as couples’ often enter into therapy with the

aim of getting the therapist on their side (Scheinkman & Dekoven-Fishbane,

2004). If the therapist connects or understands more fully with one

partner’s “story” over the other, they could quite easily become entrapped in

such a blame game. In this instance, it would be important for the therapist

to be reflexive and to take this issue to supervision so the therapeutic

relationship between themselves and the “other” partner is not jeopardised.

Blame, is noted in the literature as being a particularly significant obstacle

for the couple’s therapist to overcome (Symonds & Horvath, 2004). With

regard to Susan and Jonathan it could be that Susan, for instance, would

want the therapist to agree with her: that the cause of their problem is

Jonathan being away from home. Indeed, for me, when I initially read the

case vignette I found myself being drawn towards this argument. If I was

working with Susan and Jonathan therapeutically this is something I would

want to be aware of especially when taking into account Jonathan’s history

of “being a loner” and his current notable absence from the family home.

55

Owing to these factors, it would seem particularly important that I would

strive to avoid this pull from Susan to prevent this isolated dynamic being

crossed over into the therapy.

On the one hand I can see how SFCT might be a good therapeutic approach

to adopt in this instance as some research indicates that by focusing on the

positives of a relationship, instead of the negatives, the “blame game” so

often found in couple therapy, can be minimised (Gottman et al., 2002).

Whilst, on the other hand, I can see the benefit of developing a strong

emphatic understanding of each partners circumstance in reducing blame

between both therapist and client and indeed between the clients themselves.

Within EFCT there is a constant attempt by the therapist to emphatically

attune to each partner and to connect each partner empathically to both of

their emotions (Johnson, 2004). In this regard, I believe EFCT could also

help reduce the couple’s tendency to blame by helping them generate an

understanding of each partner’s attachment needs and fears. Through this

understanding the couple may be more inclined to respond empathically to

one other and thus reduce the tendency to blame each other for their

relational difficulties.

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Conclusion.

In response to the increased demand for couple therapy over recent years,

psychological research has sought to empirically evaluate efficacious

treatment methods for this client group. Emotionally focused couple

therapy, determined efficacious through clinical trials (Jacobson & Addis,

1993), and solution focused couple therapy, a treatment which is showing

increasing empirical and anecdotal promise (Gingerich & Eisengart, 2000),

have been compared and contrasted through an illustrative case vignette.

Through this comparison, it would appear that both therapies have their

strengths. The success of an SFCT approach for example has been discussed

in terms of focusing the couple’s attention away from the negatives of what

their partner isn’t doing to the positives of what they are doing. Whilst

EFCT has been discussed positively in relation to helping a couple

reconnect emotionally and generating emphatic responses to one another,

with suggestions made about how this may help reduce blame in a couple

dynamic.

Through the discussions of this paper, it would seem that some of the

weaknesses attached to both therapies apply to whether or not the treatment

model and the techniques deployed “fit” the couple in treatment. It has been

suggested for instance that an EFCT style maybe more suited to those

individuals who talk easily and freely in sessions and who are aware of their

emotional, internal worlds whereas an SFCT approach might be more suited

to those who find practical, reality based solutions useful. This conclusion

57

seems to highlight to me the importance of having different, psychologically

sound, theoretical models available to therapeutic practitioners so that

treatment packages can be modelled around client characteristics and their

therapeutic needs.

References.

Boddington, S.J.A., & Lavender, A. (1995). Treatment models for couples

therapy: a review of the outcome literature and the Dodo’s verdict. Sexual

and Marital Therapy, 10 (1), 69-81.

Carr, A. (2009). The effectiveness of family therapy and systemic

interactions for adult-focused problems. Family Therapy, 31, 46-74.

Ells, D. (2007). Handbook of Psychotherapy Case Formulation. Guilford

Press: New York.

Fairfax, H. (2008). “CBT or not CBT” is that really the question? Re-

considering the evidence base – the contribution of process research.

Counselling Psychology Review, 23 (4), 27-37.

Fernando, D.M. (2007). Existential Theory and Solution Focused

Strategies: Integration and Application. Journal of Mental Health

Counselling, 29 (3), 226-291.

Fisher, A.R., & Good, G.E. (1997). Men and Psychotherapy: An

investigation of Alexithymia, Intimacy and Masculine Gender roles.

Psychotherapy, Theory Research and Practice, 34(2), 160-170.

58

Gingerich, W.J., & Eisengart, S. (2000). Solution-Focused Brief Therapy:

A Review of the Outcome Research. Family Process, 39 (4), 477-489.

Gottman, J., Swanson, C., & Swanson, K. (2002). A general systems theory

of marriage: Nonlinear difference equation modelling of marital interaction.

Personality and Social Psychology Review, 6, 326-340.

Greenberg, L.S. (2004). Emotion-focused therapy. Clinical Psychology

and Psychotherapy, 11, 3-16.

Gurman, A.S. (2008). Clinical Handbook of Couple Therapy (4th Ed.). The

Guilford Press: New York.

Hoyt, M.F. (2008). Solution-Focused Couple Therapy. In Gurman, A.S,

Clinical handbook of couple therapy. New York: Guilford Press.

Jacobson, N.S., & Addis, M.E. (1993). Research on Couples and Couple

Therapy What Do We Know and Where Are We Going? Journal of

Consulting and Clinical Psychology, 61 (1), 85-93.

Johnson, S.M. (2004). The Practice of Emotionally Focused Couple

Therapy (2nd Ed). Brunner-Routledge: New York.

Kiser, D.J., Piercy, F.P., Lipchik, E. (1993). The integration of emotion in

solution-focused therapy. Journal of Marital and Family Therapy, 19, 233-

242.

Levant, R.F., Richmond, K., Inclan, J.E., Heesacker, M., Majors, R.G.,

Rossello, J.M., & Rowan, G.T. (2003). A Multicultural Investigation of

59

Masculinity Ideology and Alexithymia. Psychology of Men and

Masculinity, 4 (2), 91-99.

Scaturo, D.J. (2002). Marital and Couple Therapy: The therapist dilemmas

with dyads. Available [Online]: http://www.deepdyve.com/lp/psycbooks-

reg/marital-and-couple-therapy-the-therapist-s-dilemmas-with-dyads-

0U6Kl9S0yM. Retrieved: December 2011.

Scheinkman, M., & Dekoven-Fishbane, M. (2004). The Vulnerability

Cycle: Working With Impasses in Couple Therapy. Family Process, 43 (3),

279-299.

Symonds, D., & Horvath, A.O. (2004). Optimizing the Alliance in Couple

Therapy. Family Process, 43 (4), 443-455.

Tashiro, T., Frazier, P. (2007). The Casual Effects of Emotion on Couples’

Cognition and Behaviour. Journal of Counselling Psychology, 54(49, 409-

422.

The British Psychological Society. (2006). Ethical Guidelines. Leicester:

The British Psychological Society.

Trepper, T.S., McCollum, E.E., Jong, P.D., Korman, H., Gingerich, W., &

Franklin, C. (2008). Solution Focused Therapy Treatment Manual for

Working with Individuals. Available [Online]:

http://www.sfbta.org/researchdownloads.html. Retrieved: November 2011.

Zimmerman, T.S., Prest, L.A., Wetzel, B.E. (1997). Solution-focused

therapy groups: an empirical study. Journal of Family Therapy, 19, 125-

144.

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Appendix 1: Case Vignette.

Susan (aged 43) and Jonathan (aged 44) have been married for 25 years. They have two sons, Tim (aged 24) and Stephen (aged 18). Jonathan’s work as a Salesman has meant lots of house moves during their married life. The last move, 3 years ago came at a difficult time as Stephen was beginning “A” levels and Susan was nursing her sick mother, so Susan remained in the family home whilst Jonathan rented a flat near to work, coming home at weekends. Susan has found this separation difficult and has finally issued an ultimatum to him that he either returns home and looks for another job or they split up. Her mother has recently died, and Stephen has gone to University. Jonathan has agreed to come to therapy with Susan to explore the options. Both say that they want to stay together.

Background and History.

Exploration during early sessions has revealed that Susan, a late addition to her family, fell in love with Jonathan whilst still at school. After becoming pregnant, they married although Jonathan had yet to complete his studies at University. Since then she supported him throughout his career in her role as the homemaker. A recent decline in her own health whilst Jonathan was working away together with the terminal illness of her mother has left her feeling drained and mildly depressed.

Jonathan is quiet, and was always a “loner” at school. A chronic leg injury meant long periods in the hospital throughout his childhood. He has seen a change in Susan since he has moved away. She has put on weight and is always discontented when he does make the effort to come home at weekends. Consequently he has been coming home less frequently.

Susan is particularly close to her youngest son, and relied on him while she was ill. She misses him now he has gone to University and feels very isolated, especially now her own mother has died. In Counselling sessions it is she who expresses all the feeling, whilst Jonathan has to be encouraged to talk at all.

Things got particularly bad a few weeks ago when Jonathan came home late. Susan told him that he didn’t care about her. She was in tears, shouted at him and gave him an ultimatum to come back home. He threw his hands up saying “I can’t win” and went out to the pub, making Susan further isolated.

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THERAPEUTIC DEVELOPMENT DOSSIER.

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Counselling Psychology Practice.

Introduction.

This assignment aims to document my 3 year experience as a trainee

Counselling Psychologist working with different client groups in a number

of different NHS and private settings. I will outline the challenges I have

faced working within different settings and with different supervisors,

reflecting on my learnings from these challenges and how they have

influenced my practice as a Counselling Psychologist.

Year 1 –NHS Primary Care setting (Step 3) at North Manchester

General Hospital.

Clients I worked with.

During my time at the North Manchester General Hospital I worked with a

number of clients with different presentations. This ranged from clients who

presented with the symptoms of social anxiety and depression through to

complex grief and post-traumatic stress disorder (PTSD). I worked with

both males and females aged between 17-60 years old.

Assessment Skills.

I developed a thorough understanding of assessment skills at this placement.

This started with me observing my supervisor when she conducted

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assessments. I was able to talk to my supervisor after the session about the

questions she asked and my feelings towards particular clients. From this

we started to formulate client issues. As the service only used a CBT

approach to treatment, I learnt how to break down a client problem into

thoughts, feelings, behaviours and physiology, using the hot-cross bun

model (Padesky & Mooney, 1990). When I felt able to conduct an

assessment alone, I found the assessment form that the service used

particularly useful being a first year trainee as it was reassuring to have a

prescriptive guide from which to follow. This form also taught me the

important questions to ask when assessing client risk. It had clear sections

which focused on suicidal ideation, past and present, suicidal intent, suicidal

plans and preventative factors.

My Role.

My role at the service developed as time went on. In addition to my own

client work, I became actively engaged in the weekly service meetings

which involved discussions of new cases and I also became part of the

assessment/screening team for new client referrals.

Therapeutic Approaches.

The service at North Manchester General Hospital followed the National

Institute of Clinical Excellence Guidelines (NICE, 2008) for the treatment

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of Step 3 associated symptoms. As such the predominant treatment method

offered to clients was Cognitive Behavioural Therapy (CBT).

Initially, I found this reliance on CBT to be very helpful to me as a first year

trainee as it enabled me to get a solid grasp of this approach; from

assessment and formulation through to therapeutic intervention. It also gave

me an appreciation of the importance of subjective experience in governing

psychological treatment. For instance when working with two separate

clients, who were both referred for social anxiety and low mood, the type of

therapeutic interventions used were different because of their subjective

problems and maintenance cycles. To illustrate this point, it seems

appropriate to refer to these two clinical cases to document the different

factors that were in play which were influencing their problems and how

this then governed the CBT treatment plan. These two clients will be

referred to as Jack and Emily (pseudonyms). It is important to use

pseudonyms when documenting client work as it helps maintain client

confidentiality (BPS, 2009).

For Jack it became apparent that he was suffering with anxious thoughts

when attempting to leave his flat alone. He expressed a fear of being judged

negatively by others and his assumption that people will be critical of him

and the way he lives his life. He described a belief that he was very

different to his peers. Owing to these factors, Jack developed a series of

avoidance strategies to help him cope with his anxiety. These included

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staying at home alone and being overly reliant on his mother for socialising

and general daily chores such as shopping. These safety behaviours

(Padesky & Greenberger, 1995) were further perpetuating Jack’s problems

as they were maintaining his belief that he is different to his peers.

As the therapeutic work was governed by a CBT approach, the initial

emphasis of our work was centred on Jack’s negative automatic thoughts

when he was out alone and how these triggered his anxiety symptoms.

Accessing a client’s negative automatic thoughts is an important feature of

CBT as they are noted in the literature as being the most effective starting

point for therapy (Westbrook, Kennerley & Kirk, 2009). By accessing these

thoughts we were able to identify that Jack felt different because he is alone

and as such was hyper-vigilant to people his own age who were either out in

groups or in a couple. Owing to these negative thoughts and the assumptions

he had about himself, it seemed important that we challenge these by

introducing some behavioural experiments. Behavioural experiments in

CBT are thought to be useful because they are a good way of disproving a

client’s negative predication about themselves or the world (Wilson &

Branch, 2006). For Jack, it was thought that behavioural experiments

might help challenge his specific belief that he is different because walks

alone.

In contrast to the work done with Jack, the focus of the therapy with Emily

was on generating a formulation which documented how her alcohol

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dependency in social situations was maintaining her problems. Firstly we

addressed her apparent under-developed sense of self as this was

perpetuating her need for social approval. We introduced daily activity

diaries to help her highlight what activities she enjoyed doing and which

activities gave her a sense of achievement. This is a notably important

feature in CBT as it can help alleviate the symptoms of depression (Padesky

& Greenberger, 1995). In Emily’s case it was felt that the activity diary

could help her become aware of the amount of time she spends at home

alone but also give her an insight into her likes and dislikes, an important

factor in relation to developing a sense of self. In addition to this, we also

looked at minimising the amount of alcohol she consumes in social settings

as we identified that this safety behaviour was perpetuating her ideas about

people not liking her and thus resulted in her isolating herself further.

By working with these clients I gained an appreciation of the importance of

developing and utilising a formulation in therapy, not only for my own

understanding of the clients issues but also for the client’s themselves to

make sense of their problems. I also learnt how to adapt a therapeutic model

to fit with the individual needs of my client. For Jack and Emily the CBT

approach was used as the treatment modality of choice but the therapy itself

had a very different focus, despite them both being referred for social

anxiety and low mood.

Context Issues.

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Although I initially found the service’s reliance on the CBT model helpful

as it enabled me to develop my understanding of this approach, I began over

time, to notice certain problems with fitting a client and their needs around

the only therapeutic model offered by the NHS service where I was

working. This problem was highlighted to me through my continued work

with Jack.

Jack had been involved with psychological services for many years in

relation to his continued social anxiety and low mood. The majority of this

treatment had been directed by the principles which underpin CBT, which

by his own admission, had not helped him. Owing to this past experience,

Jack was understandably unenthusiastic about entering into another course

of CBT. I took my concerns about Jack’s suitability to the CBT model to

supervision and was advised that Jack maybe reluctant to change. This

however was not my impression of him. Jack expressed a willingness to

lead his life differently and, although accompanied by his mother, he

attended every scheduled therapy session. Under instruction from my

supervisor and because of the restrictions from the department in terms of

therapy, I continued to work with Jack in terms of his cognitions and safety

behaviours that were thought to be fuelling the problem. I did this in spite

of feeling that he would be best suited to a more systemic style of working

owing to his dependence on his mother.

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Owing to Jack’s subjective experience of therapy I began to notice that I

faced a dilemma here as I felt that the suitability of treatment was being

determined by the symptoms which Jack presented with rather than Jack

himself. This in turn, led to another failed treatment attempt, which left

Jack feeling as though his problems were unchangeable and that therapy

was unsuitable for him. This outcome left me feeling frustrated with the

service where I was working and made me feel as though my clinical

judgments as a first year trainee were not valid.

This experience taught me that the client is the expert when it comes to their

own experiences as Jack knew before treatment began that CBT was not

suitable for him. It also made me appreciate the importance of asking the

client what therapy they have received in the past and what has has been

beneficial/unbeneficial to them, questions which I now routinely ask in

assessment sessions. Finally, the experience of working in a service that

only offers a unitary mode of treatment has given me the drive to learn

about other therapeutic approaches to therapy so that in the future I can

tailor a treatment package around the needs of my clients’ rather than fitting

the individual into a therapeutic approach. This experience at North

Manchester General Hospital guided my second year placement decision.

Year 2 -NHS Secondary Care setting (Step 4) Claire House, Wigan.

69

Clients I worked with.

Throughout my yearlong placement at the secondary care facility in Wigan I

worked with clients who had a long history of mental illness and as such

were often diagnosed with a personality disorder. In addition, I was also

exposed to working with clients who were suffering with the symptoms of

psychosis, obsessive compulsive disorder (OCD) and severe depression and

anxiety. I worked with both males and females that were of working age

with the exception of one client who was 80 years old.

Assessment skills.

After a few months at the service I became involved in the screening

process which involved attending weekly referral meetings with the

Psychology team and Gateway board. These meetings involved assessing

the services suitability for new client referrals. In addition, I also conducted

weekly screening sessions with a selection of clients from which

information was fed back to the team about the clients’ presenting problem,

vulnerability and risk. This information was then used by the team to

determine the appropriate treatment package for the individuals.

This experience really helped improve my confidence in delivering

assessments as I was conducting, on average, two assessments a week. I

found that as my confidence grew I no longer needed the security of having

an assessment form to follow. As such I was able to take brief notes on the

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important points raised from these sessions and allow myself the flexibility

to move away from prescriptive questioning. I found that this style of

assessment helped the session flow more logically from point to point.

Also, by limiting the amount of time spent looking at an assessment form, I

was able to concentrate more on the individual and their presenting

problems which helped me facilitate a more empathic understanding of their

issues. This style is how I continue to conduct an assessment session.

My Role.

My role at the service developed considerably over the months I was on

placement. I moved from having a clinical caseload of three when I first

arrived, to eventually having ten clients. This increase in the number of

clients was due to demands being put on the service. At first I found this

heavy workload to be a constraint on my time, as I like to prepare

thoroughly for each session and write up my notes straight after the session

finishes, something which wasn't feasible with me only working two days a

week and with a caseload of ten. My preparation and note-taking are things

I am unwilling to sacrifice and as such I learnt, with guidance from my

supervisor, to review client progress and organise my hours in terms of

client need. For instance, for those clients who were progressing well,

fortnightly sessions were offered instead of weekly ones. This experience

gave me an appreciation of how demanding it can be working within an

NHS setting, particularly in this political climate. I learnt the importance of

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reviewing client progress so that the needs of the service could be met

without jeopardising the needs of my clients.

Therapeutic Approaches.

The real attraction of this placement for me was the diverse use of

therapeutic approaches that were offered to clients. The main therapeutic

approaches that I used with clients at this service were cognitive therapy,

psychodynamic therapy and CBT. I was also exposed to formulating client

issues from a schema focused approach and gained experience in integrating

therapeutic models to suit the subjective formulations of clients.

With one client in particular, I found it useful to be able to draw upon

different therapeutic models of treatment to help with her symptoms of

psychosis. The client in question was referred to the service by her General

Practitioner (GP) for auditory delusions, however after assessing her it

became evident that she also presented with symptoms consistent with

obsessive-compulsive disorder (OCD) and depression. For the purpose of

this assignment, this client will be referred to as Louisa (pseudonym).

Louisa was the first client I had worked with who presented with a number

of psychological difficulties. Owing to this I found it useful to have a

detailed formulation of her presenting issues from which appropriate

therapeutic interventions could be applied.

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In accordance with some of the treatment literature on auditory delusions

which detail the importance of challenging a client’s perception that the

auditory delusion is real (Chadwick & Birchwood, 1996), we took example

from cognitive therapy in terms of thought challenging (Beck, Rush, Shaw

& Emery, 1979) to try and loosen her once rigid cognitions that the woman

she could hear playing the piano was real. In terms of Louisa’s low mood,

we introduced an activity diary to help her see how much of her day was

spent sitting and thinking about her auditory delusion. This CBT

intervention was used not only to help Louisa recognise that she might want

to incorporate more varied activities into her day but also to make her

realise that she often listens out for the “woman playing the piano” which in

turn increases the frequency of her delusion. In addition to Louisa’s

auditory delusion she also suffered with negative intrusive thoughts about

wanting her husband and daughter to die. These thoughts were

understandably very disturbing to Louisa and as a consequence she believed

she was a bad person. To work on this we introduced some mindfulness

concepts (Alidina, 2010) to help Louisa recognise that a thought is just a

thought in order to tackle the negative judgements she made about herself

for thinking about her husband and daughter’s death.

In comparison to my first year placement where the choice of treatment

modality was taken away from me, I found this eclectic way of working

very refreshing. I enjoyed making informed therapeutic decisions about

appropriate treatment interventions based on Louisa’s presenting issues and

problems and the flexibility the service gave me in terms of treatment

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choice from Louisa’s perspective. As this was the first time I had worked

with a client in such a way, i.e. eclectic, I found it useful to regularly review

Louisa’s progress both qualitatively, using the Beck Depression Inventory

(BDI-II: Beck, Steer & Brown, 1996) scale to monitor her depressive

symptoms and quantitatively to assess the frequency/severity of her

delusions and intrusive thoughts.

Year 3 – The Priory Group – Inpatient Eating Disorder Service,

Cheadle Royal Hospital, Manchester.

Clients worked with.

In contrast to my previous NHS community mental health placements in

years one and two, my third year placement at Cheadle Royal Hospital

offers an In-Patient service for those individuals specifically suffering with

an eating disorder. My individual caseload here consisted of women aged

between 18-61 years who were suffering with anorexia nervosa, bulimia or

both anorexia and bulimia. In addition to my individual work I also ran

weekly group therapy sessions on the concepts of mindfulness and emotion

regulation. In these groups, I worked with both males and females of

working age who were suffering with an eating disorder.

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My Role.

During my time at Cheadle Royal Hospital the psychology department went

through a major re-structuring process. As I was part of the weekly

psychology meetings, I was involved in the decision making process to re-

structure the team so that each unit on the Ward had its own head of

psychology. The reason for wanting this change was to get more

psychological input in the multi-disciplinary meetings so that client needs

could be understood from a psychological perspective as well as a medical

one. We also decided to appoint an over-arching head of psychology for the

two units whose job would involve assessing and formulating each client

referred to the Ward. After a week piloting this new structure it became

apparent that the main head of psychology would not be able to conduct this

process alone owing to service demand and time constraints. Because of

this I, along with other members of the team, became involved in the

assessment/formulation process for new referrals. This process involved

individually assessing new clients so that a psychological formulation could

be generated and then passed on to the wider mental health team to inform

them of the appropriate treatment package for that client. The assessments

involved conducting a clinical interview and administering psychometric

measures, such as the Eating Disorder Inventory-3 (EDI-3: Garner, 2004). I

delivered the information from these sessions and the results of the EdI-3 to

the team in both written and verbal formats.

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In addition to my involvement with the re-structuring process, I attended the

allocation meetings which assign clients to therapists in accordance with

their therapeutic need. In one of these meetings it was brought to my

attention that a client on the ward had requested she see me for individual

therapy. Although flattered by this request, I made the difficult decision to

decline; she was already seeing another member of the psychology team and

had no clear reason to want to see me instead, as I had not had any

involvement with her in the past. After looking at her assessment and

formulation notes and speaking to her current therapist, it became apparent

to me that the client would become avoidant of situations just as she was

starting to go deeper into understanding her problems. This request,

therefore, appeared to be another cycle of avoidance and as such it seemed

to me that taking her onto my caseload would not be therapeutically

beneficial to her as she needed to address this pattern of avoidance rather

than run away from it. My decision was accepted by the team and as such

she continued to see her current therapist.

Therapeutic Approaches.

In addition to CBT the service, and indeed my supervisor, advocated the use

of Emotionally Focused Therapy (EFT) as a treatment option for clients on

the Ward. This type of therapy is used in response to the research literature

on eating disorders which shows Alexithymia to be a common problem for

this client population (see Cochrane, Brewton, Wilson and Hodges, 1993;

Fox & Power, 2009). Indeed when working with my clients I found

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emotional suppression to be a central function of their eating disorder. With

guidance from my supervisor and in response to my formulations, I started

to work therapeutically using EFT with two of my clients. Informed by this

approach, I used the empty chair technique with these clients to elicit

emotional expression from what they termed “two parts of themselves”; the

part that wanted to eat and the part that did not. This style of work helped

both clients recognise the function of their eating disorder. This then gave

them insights into what they needed to move forward by addressing what

had been neglected in their life i.e. factors such as love and security.

This experience made me realise that in the past I have overlooked the role

of emotion in my therapeutic work with clients in favour of assessing

cognitive and behavioural difficulties. Having witnessed the benefits that

can be drawn from an approach which puts emotional expression at the

heart of therapeutic change, I feel that going forward, I will be more likely

to assess a client’s relationship with their emotions and how this may be

feeding into their difficulties.

Context Issues.

In contrast to my work within an NHS setting, where discussions of client

information between colleagues is kept vague and general (with the

exception of supervisee to supervisor contact), within my in-patient setting,

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I found the confidentiality “laws” to be far less constrained. I quickly

discovered when I started working at this placement that content-specific

information was passed on from therapist to other key members of staff who

were involved in the clients care. This came as quite a surprise to me and

initially I felt very uncomfortable when colleagues would approach me for

information from my therapy sessions with clients, as I am aware of my

professional code of conduct and the guidelines covering confidentiality. I

took my concerns to supervision and was informed that information was

passed on to other members of staff so that an informed and consistent

treatment package could be utilised by all staff members involved with each

individual client.

Whilst this discussion helped me understand the different systems used in an

in-patient setting compared to a CMHT setting, where different mental

health disciplines are constantly involved in providing the best care for

clients, I felt I should have been informed of this before starting to work

with clients. As I was not made aware of this when I started the placement I

felt my clients had been misinformed of my confidentiality limits. This left

me feeling extremely uncomfortable as I am aware of how important

confidentiality is in maintaining trust in a therapeutic relationship. I

rectified this by explaining the limits of my confidentiality with my clients

at the first appropriate opportunity and I made my supervisor aware of my

unease at not being informed of this policy at the start of my placement.

Owing to this experience, I now realise that I cannot assume that rules

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governing confidentiality are universal and I must be cognisant of varying

working practices at different workplaces.

Supervision.

By working in three different placement settings throughout my training I

have not only gained experience of working with different clients and

differing presentations but I have also become exposed to different

supervisory styles. Through this experience I have learnt that I thrive off

supervisors who encourage me to get a detailed” feel” for the client and the

lives they lead by not just concentrating on the symptoms that they present

with. My second year supervisor in particular taught me how to generate an

informed impression of the client by getting an in-depth view of the client’s

experiences and their responses to these experiences in order to generate a

more informed formulation of their difficulties. I enjoyed the

encouragement my second year supervisor gave me in terms of exploring

what it is like for me working with different clients and how identifying the

dynamics between us in therapy can help the client overcome some of the

challenges faced in their daily lives. This supervisory style has influenced

the way I work with clients as I am more of an inquisitive practitioner than I

was in my first year training. I now strive to understand my clients, their

behaviours, life choices and emotional reactions to situations from a

psychological standpoint instead of solely concentrating on the symptoms

that present with.

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I feel that the way I use supervision has also changed over the last three

years. In my first year placement I understood supervision to be a place

where I could look for direction from my supervisor to tell me what to do

with my clients. Whilst I appreciate that this was probably what I needed

from supervision at this time, looking back I do feel it restricted my growth

as an autonomous practitioner. This changed in my second and third year

placements however as I was introduced to a more process-centred approach

to supervision. I now enjoy the freedom of exploring an issue together with

my supervisor to get an informed understanding of what is going on for my

clients. I feel that this has given me the chance to recognise my abilities as a

reflexive practitioner which in turn has given me the confidence to listen to

my internal supervisor in sessions.

Future Direction.

Owing to my choice of placements over the last three years, I feel I have

gained experience working in different settings with a variety of client

problems. This experience has enabled me to make an informed decision

about my future career as a practicing counselling psychologist in terms of

where I would like to work and who I would like to work with. Although I

enjoyed working in all three placements and feel as though each one taught

me something, my role at the secondary care CMHT setting gave me the

most job satisfaction. I found that I enjoyed working with the complexity

and diversity of secondary care issues and relished the flexibility the service

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gave me in terms of therapeutic intervention. I believe these learnings will

influence my future work decisions when I am qualified.

References.

Alidina, S. (2010). Mindfulness for Dummies. Wiley & Sons Ltd: London.

Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy

for depression. Guilford Press: New York.

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck

Depression Inventory- II. Psychological Corporation: San Antonio.

Chadwick, P., & Birchwood, M. (1996). Cognitive Therapy for Voices. In

G. Haddock & P.D. Slade. Cognitive-Behavioural Interventions with

Psychotic Disorders. Routledge: London.

Cochrane, C.E., Brewerton, T.D., Wilson, R.D., & Hodges, E. (1993).

Alexithymia in the eating disorders. International Journal of Eating

Disorders, 14(2), 219-222.

Fox, J.R.E., & Power, M.J. (2009). Eating Disorders and multi-level

models of emotion: An integrated model. Clinical Psychology and

Psychotherapy, 16(4), 240-267.

Garner, D.M. (2004). Eating Disorder Inventory-3. Professional Manual.

Psychological assessment resources: Lutz, FL.

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National Institute of Clinical Excellence (NICE) Guidelines (2008). NICE

Guidelines. Available [Online]: www.nice.org.uk/guidence/CG. Retrieved:

12.02.12.

Padesky, C., & Mooney, K.A. (1990). Presenting the Cognitive Model to

Clients. Available [Online]: www.padesky.com/clinicalcorner/pdf.

Retrieved: 02.02.12.

Padesky, C., & Greenberger, D. (1995). Clinician’s Guide to Mind Over

Mood. Guilford Press: New York.

The British Psychological Society (BPS, 2009). Code of Ethics and

Conduct. Available [Online]: http://www.bps.org.uk/document-download-

area/document -download$.cfm?file_uuid=pdf. Retrieved: 12.02.12.

Westbrook, D., Kennerley, H., & Kirk, J. (2009). An Introduction to

Cognitive Behaviour Therapy. Skills and Applications. London: Sage.

Wilson, R., & Branch, R. (2006). Cognitive Behavioural Therapy For

Dummies. West Sussex: Wiley.

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Reflective Essay: Professional Issues.

Introduction.

The following account is a personal reflection of my experiences throughout

my three year training on the Practitioner Doctorate in Counselling

Psychology course at the University of Wolverhampton. I have drawn upon

the most predominant aspects of my life experiences before enrolling onto

the course, and my continued experiences throughout my training, to help

demonstrate how these have shaped my own personal philosophies as a

Counselling Psychologist.

My life prior to training.

I enrolled on to the Practitioner Doctorate in Counselling Psychology course

in September 2009. At the age of 25, I began to realise that what I was

doing with my life wasn’t making me happy. I felt like I was stuck in a job

that was giving me no satisfaction and I constantly felt under pressure from

my parents to “do something with my life”. The problem was I didn’t know

what I wanted from life. I had spent the majority of my childhood and early

adulthood being told what to do; complete my GCSE’s and A-levels and

then go to University. My life had followed a very nice, neat, guided path

that was already mapped out for me. It didn’t require me to think about

what I wanted to do or what the next step would be.

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This path that I had been following suddenly ended after I completed my

undergraduate Psychology degree in June 2005. I felt as though there was

an expectation that I, the only person in the family who had obtained a

degree, would fall into a well paid, well respected job that my parents would

be proud of. Around this time, I felt as though I was constantly striving to

please my parents. I was searching for a way to get back onto the guided

path that I had been following all my life; the path that showed me where to

go to make my parents proud of me. The problem was that my reliance on

my parents’ ideals of what I should be doing had left me with no real idea

about what I actually wanted for myself.

In amongst my confusion at this time, my father suggested I apply for a

Sales Manager position in the housing company where he worked. I

accepted, although I knew my heart wasn’t in it; I hated sales. To my relief I

failed the first round of interviews, but my father, being the Managing

Director, “pulled some strings” and got me through to the second interview

stage. I felt in turmoil. I didn’t want the job but at the same time I didn’t

want to go against my father’s wishes. I remember having a powerful gut

feeling which I couldn’t ignore that was telling me to turn the job down. In

response to this feeling, I realised that I would have to tell my father that I

wasn’t going to attend the second interview.

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This was the first time in my life that I had ever listened, and responded to,

my feelings. It gave me the drive I had needed to explore what I did want

from life and from my future career instead of relying on this dependent-

rescuer dynamic that both my parents and I were in. This was the time

when I began to realise I was tired of striving for their approval. Instead, I

wanted to do something for me; something that I had decided upon,

something that would make me happy.

What made me decide to apply for Counselling Psychology?

Looking back I believe on some level I knew that entering onto the

Counselling Psychology course would be personally beneficial to me. At

the start of the course I was unable to verbalise why I had chosen

Counselling Psychology as my profession, other than the fact that I wanted

to help people. I had been given a taste of what counselling entailed through

the counselling skills courses I had completed prior to starting the

Doctorate. At the time of completing these courses I was working in a HR

department of a law firm, where I felt under-valued and very beholden to

my manager. Owing to the job I was in I felt pressurised to achieve results

and felt that my actions always had to be justified.

I found that the evening counselling courses I had enrolled on gave me some

relief from this business world environment where there always needed to

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be a right or wrong answer to things. I felt instantly connected to Carl

Roger’s humanistic concepts of empathy, congruence and unconditional

positive regard (Rogers, 1963) and I found it very therapeutic going to the

classes, as often the teaching staff would demonstrate these concepts to us

through a counselling session role play, where we were the clients. For me,

the concepts of congruence and UPR (Rogers, 1963), really offered me an

insight into what I needed from my life and what perhaps had being missing

from my development so far. I wanted myself and others to honour my

feelings and decisions without feeling the need to justify them. Counselling

Psychology for me was an extension of this learning. From researching the

course, it became apparent that I would be given the opportunity to surround

myself in the humanistic concepts that I had connected so well with during

the counselling courses, whilst also allowing me to explore and learn about

other treatment modalities in the hope that these too could offer me some

personal insights.

Once I had enrolled onto the course I found that my experiences on

placement and within my own personal therapy were the most influential

contexts for my personal and professional growth.

My First Year Placement.

My first year placement was in a Primary Care service situated in North

Manchester. The service was made up of clinical psychologists, one of

which was my appointed supervisor, and other assistant psychologists. The

department was focused on following the National Institute of Clinical

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Excellence guidelines (NICE, 2008) for the treatment of primary care

symptoms and thus the main method of therapy offered to clients was

Cognitive Behavioural Therapy (CBT).

Initially, the service’s reliance on CBT provided a welcome relief for me.

As an unconfident first year trainee, I found it reassuring to have treatment

manuals at my disposal that had been specifically written for clinicians and

prescriptive formulations which could be followed to help generate a

psychological understanding of my clients’ problems. Where necessary,

with regard to treatment intervention, there were thought challenging

worksheets which could be followed, daily activity diaries which could be

completed and specific behavioural experiments which could be tailored to

the individual needs of my clients to help achieve therapeutic change. The

structured approach to therapy that CBT offered, in terms of agenda setting,

was also beneficial to me as it helped ease my anxiety around “what to do”

with clients in a session.

This concept of wanting to know “what to do” with my clients in therapy

was a big sticking point for me when I first started working therapeutically

with clients one to one. I remember thinking that in order to be a “good”

therapist I needed to be proactive in sessions to help show my clients how to

“get better”. In this sense CBT fitted in with my impression of what it

meant it be a “good” therapist as treatment seemed to be focused on

changing a client’s symptomatology by adopting certain cognitive or

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behavioural interventions into their treatment plan. At the time, I was very

content with this style of working. It seemed to be helping my clients, it

provided me with clear guidance on how to formulate and match therapeutic

intervention to my clients presenting symptoms whilst also enabling me to

be proactive in therapy and therefore feel as though I was doing something.

Whilst this was the case, I came to realise that this approach wasn’t suitable

for all my clients. For instance one of my clients in my first year placement

had received two courses of CBT before coming to see me for therapy,

neither of which had worked. In addition, one of my clients in my third year

placement, had received a similar pattern of treatment, which again hadn’t

helped because she felt as though the treatment was telling her to change,

which fed into her low self worth. Alongside these client experiences I

began to recognise, through my own personal therapy, that the very issues

CBT seemed to be maintaining for me, in terms of wanting to be a

proactive, “good” therapist, were the things I needed to explore.

How my insights from personal therapy connected to my work with clients.

I found personal therapy very hard to engage with in the beginning. I didn’t

know what to say or how to be in my sessions and was therefore looking for

guidance from my therapist on where to start. At this time, I remember

feeling frustrated with my therapist as, it appeared to me, that she was not

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helping me engage in the process. After a few sessions I began to open up

about my feelings of frustration.

The disclosure of how I was feeling led onto the insights mentioned above

about always being rescued by my parents and therefore not having any real

sense of my internal world. I began to recognise that this dynamic had

filtered into the therapy room. I wanted my therapist to tell me what to do

and when she didn’t I became frustrated with her. By going through this

process, I began to recognise that my therapist was staying with my

struggles. She was facilitating an environment where I was the expert; I was

recognising my dilemmas and I was the one who was generating my own

conclusions and solutions. I was the one who was living through the

experience and thus she was not the person to save me from them.

Although I wasn’t given the answers by my therapist I felt understood and

validated in every stage of this process and subsequently came away from

the sessions feeling very empowered.

These insights from my own therapy enabled me to recognise that my initial

view of a “good” therapist was in conflict with how I was experiencing my

own therapist. By reflecting on my experiences I was able to connect my

perceived role of a therapist to the parent-rescuer dynamic I had experienced

growing up. Only this time, I was trying to be the rescuer for my clients.

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Whilst I have seen first-hand the value of not being rescued by my own

therapist, I feel that this maybe my Achilles Heel when I work with clients

in therapy. I have started to recognise that with certain clients my default

setting of wanting to fix their problems is easily triggered. In one such

instance, I was working with a client who was very defensive at the start of

therapy. She hardly spoke in our sessions and when she did she speak she

appeared to be very angry with me; telling me that I was not the right

therapist for her. My reaction to her anger was to do something in order to

rectify the way she felt about me. After all I wanted to be the “good”

therapist who made things better for her. I began feeling agitated because I

was taking her comments personally. I bombarded her with questions and

quickly reached for my pen and paper to draw out an agenda of how we

could help the situation.

By reflecting on how I had responded to this client I was able to see that

CBT for me had become my default setting in my attempt to rescue the

client to try and help her engage. In response to my feeling of agitation I

had felt the need to do something in the therapy i.e. set an agenda, obtain

her goals etc. I started to reflect on how my own therapist had responded to

my initial struggles when trying to engage in therapy and realised that

instead of trying to do something to help me, she had simply stayed with my

feelings of frustration. I began to recognise that this way of working could

start to help me alter my impressions of what it meant to be a “good”

therapist. If I could stay with my client’s struggles instead of trying to

change them I could start to limit the pressure I was putting on myself “to

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do things” in therapy and thus help the client explore what her defences

were really about. This experience helped give me an insight into the type of

therapist I wanted to be. I wanted to move away from this idea that I needed

to rescue my clients. Instead I wanted to foster a more reflective style of

working instead of trying to do something to help the client change in some

way.

Supervision.

As well as recognising that I wanted to work in a more reflective way within

therapy, I also started to notice that I wanted the same within supervision. In

my first year placement I entered into supervision with the idea that my

supervisor was somebody I had to impress, an authoritative figure that had

power and was therefore somebody I should answer to. After all, this had

been the way I had lived my life up until now; with others telling me what

to do, and me obeying them.

Unsurprisingly I felt very much like a student in my first year supervision

sessions. My supervisor would teach me about the concepts of CBT in

terms of formulation and therapeutic intervention and I would go away and

practice them. Initially I was relieved to have this input. I was pleased that

I had someone guiding me through. After a while though, I began to

recognise that I was finding the lack of autonomy in this placement setting

difficult. I felt as though I was at the stage where I wanted to challenge

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myself. I was starting to feel that my professional growth was being

constrained by the teacher-student dynamics within supervision and within

the wider context of the service’s reliance on CBT. I wanted to learn more

about other approaches and foster my autonomy, after all these were the

things that initially attracted me to Counselling Psychology.

My Second and Third Year Placements.

I chose my second and third year placements based on the fact that neither

placement was prescriptive in terms of what treatment modality could be

used with clients. Whilst I knew I wanted to experience a more moment-to-

moment style of therapy than I had experienced when working with a strict

CBT approach, I found it scary at first to let go of my CBT treatment

manuals which had become my safety net. Whilst I was feeling this way, I

knew that in order for me to stay true to the type of therapist I wanted to be,

I would need to stay with my struggle instead of trying to do something to

change it. In doing so, I began to realise that often the difficult part of

overcoming a challenge is the effort I expend when trying to change a

situation to immediately make it better. I found that if I could actually just

sit and accept the way I was feeling, the sense of struggle reduced and thus

so did the difficulty.

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Through my experiences in my second year placement, I began to connect

the aforementioned learnings to the concepts which underpin Mindfulness.

Through more exposure to these techniques in my third year placement and

in the third year personal development group I began to feel even more

connected to these principles, which fall under the umbrella term Third

Wave CBT (Fletcher & Hayes, 2006). I began to notice that I wanted to

adopt these principles into my everyday life as well as in my work with

clients as they offered me a refreshing take on how to respond to life’s

challenges.

Whilst I found that in some instances working with CBT in the traditional

sense helped some of my clients change and restructure their thoughts or

behaviours, I found the concepts attached to Mindfulness to be far more in-

keeping with my values as a Counselling Psychologist. They seemed to

focus on the relationship between my client and their thoughts and feelings

and represented to me a freedom to just accept, instead of trying to change.

This was a new concept for me owing to my upbringing where I was always

encouraged “to do” something. I have found the adoption of these concepts

particularly useful with clients who present as defensive in therapy as they

have helped me recognise the importance of exploring these defences with

the client instead of taking their defensives personally.

Supervision.

As mentioned above, throughout the training, my idea of what it meant to be

a “good” therapist was starting to waver. Owing to this, in my second and

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third years, my expectations of how I should be in supervision also changed.

Once I stopped trying to impress my supervisors I began to recognise that I

was able to learn more and become more reflective in supervision. In my

third year, I began to discuss the power dynamic between my supervisor and

I in terms of student-professional which was something I had never done

before with my past supervisors. This to me symbolised a major turning

point in my development as I was starting to recognise and share my own

personal experiences within supervision. My supervisor was able to accept

and validate my concerns over this dynamic and together we were able to

reflect on this when appropriate in our supervision sessions.

This experience has really made me appreciate the profession I am in.

Comparing it to my previous job in HR, where I always felt under pressure

to do the right thing, it felt liberating to have another professional encourage

the disclosure of my perceived “negative aspects”. This has shown me that

one of my most important roles as a Counselling Psychologist is to

recognise and explore my struggles with clients within supervision instead

of trying to impress. I believe this recognition is helping me to grow

professionally as I am now more open to exploring things that I have

difficulty with within supervision.

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How my experiences have shaped my philosophies as a Counselling

Psychologist.

My experiences of working in different placements, with different treatment

modalities and supervisors, and my experiences within personal therapy

have really helped shape my philosophies as a Counselling Psychologist. In

particular I have recognised the importance of validating an individual’s

experience as true and therefore not trying to change them or their situation

in some way to “make it better”. As previously mentioned, this view

conflicted with my initial impression that the therapist was the expert and so

should provide clients with the answers to their problems. Seeing first-hand

the importance of not being rescued in therapy, I strive to empower my

clients by exploring their difficulties instead of trying to rescue them by

doing something to make their situation better.

Whilst I feel strongly about this concept I do recognise that it might not be

easy to uphold. Firstly I recognise that being the rescuer for my clients is

something I need to be constantly aware of owing to my experiences

growing up. Secondly I recognise, through my own process of change

throughout the course, that certain professional contexts can feed into this

dynamic for me by reducing my feeling of autonomy as a practitioner. I

believe that my experiences within my first year placement for instance

where I felt very guided, not only by my supervisor, but also by the wider

placement setting in terms of being told what treatment modality to use,

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sought to limit my professional growth, in much the same way as my

personal growth had been limited by following my parents’ guidance.

Looking back now, I can see that one of my original drivers in choosing

Counselling Psychology as my profession was to help foster my

independence. I believe this is why I felt so connected to the humanistic

values that I was exposed to in my counselling courses prior to enrolling

onto the Doctorate. The ideas of acceptance and autonomy I feel have been

linked in my personal journey throughout the Doctorate course. I have not

only become more aware of my own internal world, which has fostered my

autonomy, but I have also become more accepting of it. I have recognised

through my training that autonomy is something that I need in order to feel

connected with myself. I have found that autonomy for me is very much

represented by a freedom to choose which treatment modality to use in

therapy and that this diversity drives my professional enthusiasm. This also

seems to be a core component of what it means to be a Counselling

Psychologist as we can offer a diverse range of therapeutic styles to clients

instead of having a “one model fits all” approach to treatment. I feel that

these learnings are very much guiding my current views of therapy and the

type of therapist that I want to be.

How I intend to maintain my philosophy.

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Firstly, owing to the fact that personal therapy has been so beneficial to me,

I am reluctant to give it up. I am planning, once in paid employment, to

attend regular therapy sessions with my current therapist who is a

Counselling Psychologist. For me it has been so important to have this

contact with a therapist from my own discipline, particularly when working

in the National Health Service (NHS) which can so often be medically

informed. Particularly in my first year of training, when I was in a setting

where there was so much emphasis on diagnosis and treatment outcome, I

found it really useful to draw example from her style of working as it

confirmed the importance of my humanistic roots as a Counselling

Psychologist that the client is the expert.

Secondly I came to realise, particularly through my second and third year

placements that working eclectically with clients in therapy is something I

enjoy. I found I relished making informed therapeutic decisions about

appropriate treatment interventions based on my clients presenting issues

and problems and the flexibility the services gave me in terms of treatment

choice from my clients’ perspectives. I feel this flexibility helped develop

my confidence as an autonomous practitioner as I was able to suggest

different ways of working with my clients. This insight has given me the

motivation to continue studying different treatment modalities that I haven’t

been exposed to on the course. In addition it has made me realise that in the

future I would like to work in a setting which encourages the use of

different therapeutic styles.

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Finally, my experiences throughout my training have taught me the

importance of exploring and accepting the subjective experiences of my

clients. I feel this concept is central to the Counselling Psychology

profession and is something that I am trying to promote through my

research. As part of my thesis I have recently completed a review paper

which explores the importance of adopting a qualitative mode of enquiry in

the treatment of post-traumatic stress disorder (PTSD). This idea came to

me when I worked therapeutically with a client who presented with the

symptoms of PTSD using the recommended exposure based interventions

(NICE, 2008). Through this process, I not only found that my client was

struggling to engage in the treatment but that I was also finding the process

of exposure work to be very demanding. In response I found myself

wanting to explore other treatment methods for PTSD at the level of client

experience to ascertain what components of a treatment method make it

effective in real world practice. I feel that by adopting an epistemological

stance that honours the exploration of client experiences in my research I

can help generate a fuller picture of what is useful to my clients in therapy.

I feel this approach to research values not only the subjective nature of

Counselling Psychology but also the “practice-led” element which is used to

define our profession (BPS, 2005). This is something that I intend to adhere

to more fully in my future research.

Conclusion.

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I have gained so much from completing the Practitioner Doctorate in

Counselling Psychology course. Through this process I feel I have moved

from being a person who strived to intellectualise all of my experiences to a

person who strives to listen to, and accept, my emotional world. The

insights generated from my own personal therapy have helped me connect

my childhood experiences to my initial views of what it meant to be a

“good” therapist. I began to recognise how this ideal was impacting on my

client work, dictating my adherence to particular treatment models and

influencing my experiences within supervision. These insights have not only

helped me identify the importance of accepting my own and my clients

internal worlds but that also exploring and reflecting on a

situation/feeling/behaviour can often be more beneficial than trying to

change it. I intend to honour my learnings going forward by engaging in

the study of different treatment modalities and through my involvement in

promoting the profession through more practice-led research.

References.

Fletcher, L., & Hayes, S.C. (2006). Relational Frame Theory, Acceptance

and Commitment Therapy and a Functional Analytic Definition of

Mindfulness. Journal of Rational-Emotive and Cognitive-Behavioural

Therapy, 23 (4), 315-336.

National Institute of Clinical Excellence (NICE) Guidelines (2008). NICE

Guidelines. Available [Online]: www.nice.org.uk/guidence/CG. Retrieved:

12.02.12.

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Rogers, C. R. (1963). The concept of the fully functioning person.

Psychotherapy, 1 (1), 17-26.

The British Psychological Society (BPS) (2005). Division of Counselling

Psychology. Professional Practice Guidelines. Available [Online]:

http://www.bps.org.uk/downloadfile.cfm?file_uuid=10932D72-306E-1C7F-

B65E-875F7455971D&ext=pdf. Retrieved: 18.04.12.

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RESEARCH DOSSIER.

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Search Strategy.

Science Direct, PsychInfo and Swets Wise databases were used to identify

literature and research from peer-reviewed journals relevant to the current

thesis. In addition, Google Scholar and Google Books were used as

preliminary search engines. Combinations of the following terms were used

to identify relevant articles: PTSD, Exposure Therapy, EMDR, Combat,

Veterans, limitations, treatment failure, dropout, client satisfaction, clinician

adherence, shame, anger, guilt, engagement. The papers selected by the

search engines were examined for compatibility to the current research and

extra literature was obtained from the articles reference lists.

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Preface to the Research Dossier.

Post-traumatic Stress Disorder (PTSD) has been regarded as a standalone

disorder since its categorisation in the Diagnostic and Statistical Manual 3rd

edition (DSM III) in 1980. Recognition that mental health problems can

derive from particularly disturbing, life threatening events came after World

War One when soldiers returned from combat with psychological problems

that could not readily be explained by psychiatrists (Jones & Wessely,

2005). At the time, the terms “shell shock” and “war neurosis” (Tanielian &

Jaycox, 2008) were used to describe the acute effects of battle that

encompassed an array of psychological symptoms which we would now

refer to as PTSD.

The recent wars in Iraq and Afghanistan have resulted in a new wave of

military personnel being deployed for combat. The mental consequences of

combat are more readily recognised in recent times, by both mental health

professionals and society in general. Alcoholism is recognised as the main

problem in returning veterans in the UK with prevalence rates of

approximately 30% in males aged between 16-24 years (King’s Centre for

Military Health Research, 2010). Current epidemiological studies suggest

that 4% of combat troops returning from the wars in Iraq and Afghanistan

suffer with posttraumatic symptoms in the United Kingdom (King’s Centre

for Military Health Research, 2010) with higher rates of 15-20% recorded

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for veterans from the United States (Hoge, Castro, Messer, McGurk, Cotting

& Koffman, 2004).

PTSD is accepted as being accompanied by various co-morbid problems.

For example psychological and psychosocial co-morbidities such as

depression, dissociation, social avoidance (Bremner, Southwick, Brett,

Fontana, Rosenheck & Charney, 1992) and anger (Forbes, Parslow,

Creamer, Allen, McHugh & Hopwood, 2008) are recognised as common,

particularly in those individuals presenting with PTSD in the aftermath of

war (see Frueh, Turner, Beidel, Mirabella, Walter & Jones, 1996).

Identifying appropriate psychological therapies that can be useful in helping

reduce the symptoms of combat-related PTSD and the associated co-

morbidities is therefore of considerable interest.

The current ways in which appropriate therapies are identified for

psychological problems are a pertinent issue (Hemsley, 2010). In the UK,

the National Institute of Clinical Excellence guidelines (NICE) have

produced a framework for evaluating therapies which currently emphasise

the importance of outcome measures in determining “best practice”

(Newnes, 2007). This method of evaluation deems therapies efficacious if

they consistently show their usefulness in reducing the symptoms of a

particular psychological complaint through randomised control trial

conditions (RCTs).

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Whilst the Counselling Psychology profession recognises the importance of

therapeutic regulation (see Nowill, 2010) the current method of evaluation

(Fairfax, 2008) and the limitations of utilising only those therapies that have

performed well in RCTs in actual clinical practice has been strongly

questioned (see Newnes, 2007). It is argued by some that the success of

cognitive behavioural therapies (of which exposure therapy is akin) stays

solely within the clinical trial from which the results were generated.

Individual differences found in both client and therapist for instance can

stand to limit the transferability of findings from research into clinical

practice (Onwuegbuzie & Leech, 2005). For Counselling psychologists

who recognise that each individual client may experience a situation, a

psychological problem or a therapeutic model differently (Corrie, 2010),

this current way of therapy evaluation can be seen to be particularly

limiting.

For the treatment of PTSD and its corresponding subgroups which include

combat-related PTSD, these concerns are not uncommon. Exposure therapy

is shown to be an efficacious therapy for reducing the symptoms of PTSD

(Foa et al., 2005; Schnurr et al., 2007), and yet there is a disconcerting

mismatch between the efficacy of exposure therapy in reducing the

symptoms of PTSD as determined through clinical research trials and its

effectiveness when applied to real world clinical practices, particularly for

veterans of war (Erbes, Curry & Leskela, 2009; Garcia, Kelley, Rentz &

Lee, 2011). In psychological therapies where both efficacy and

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effectiveness are of considerable importance for any psychological change

to occur, this distinction needs to be addressed.

It is argued in Paper One of the Research Dossier (full publication reference

supplied in Appendix 1), that the most popular way of exploring the

usefulness of therapeutic interventions in PTSD i.e. through objective

outcome studies, may sometimes overlook, or fail to pay sufficient attention

to, factors of great importance to therapists in real-world practice. In a

therapeutic field where there is a notable distinction between treatment

efficacy and treatment effectiveness, the current review aims to compare

and contrast two PTSD treatments which fall either side of this research-

practice distinction: exposure therapy and Eye-Movement Desensitisation

and Reprocessing (EMDR). In comparison to exposure therapy, EMDR is

regarded as a less theoretically grounded therapy with weaker evidence of

efficacy. Yet it appears to be more accepted by clinicians and clients in

practical settings. Intrinsic factors which could contribute to this anomaly

are discussed throughout the paper. These factors suggest that therapies

which differ from normal evidence-based practice convention still warrant

exploration as they can help develop our understanding of what makes a

therapeutic model practically effective.

The aim of Paper Two (prepared in line with author guidance for the Journal

of Clinical Psychology, see Appendix 2), is to empirically explore the

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practical effectiveness of another therapeutic model, specifically designed

for combat-related PTSD: Spectrum therapy (for a full description of the

clinical protocols involved in Spectrum Therapy, please refer to Appendix

3). Much like EMDR, Spectrum therapy seems to highlight the efficacy-

effectiveness distinction in the treatment of PTSD. Spectrum therapy is not

as theoretically grounded as exposure therapy nor does it have any current

evidence of efficacy. It does however seem to be gaining momentum in

charitable organisations in the UK and is well received by veterans who

have previously dropped out of exposure therapy. Exploring veterans’

reasons for their engagement in Spectrum therapy and their disengagement

from exposure therapy could help increase our understanding of the factors

related to both therapies which either help or hinder practical engagement.

The qualitative study presents a number of important themes which can be

used to inform professionals on how to start closing the gap between

efficacy and effectiveness in PTSD treatment.

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Contents.

1.0 PAPER ONE: CRITICAL LITERATURE REVIEW.

Distinguishing between treatment efficacy and effectiveness in Post-

traumatic Stress Disorder (PTSD): Implications for contentious

therapies.....................................................................................................112

1.1 Abstract..........................................................................................113

1.2 Introduction....................................................................................113

1.3 Post-traumatic Stress Disorder (PTSD)..........................................115

1.4 Exposure-based CBT: The Zeitgeist of the Disorder.....................116

1.5 EMDR: Theoretical Substance.......................................................117

1.6 EMDR: Weaker Evidence of Efficacy...........................................119

1.7 The Effectiveness-Efficacy Distinction Applied to

EMDR.............................................................................................120

1.7.1 The client experience..........................................................121

1.7.2 The therapist experience.....................................................123

1.7.3 The EMDR Movement........................................................125

1.8 Client-Centred Research................................................................128

1.9 Conclusion.....................................................................................130

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2.0 PAPER TWO – RESEARCH REPORT.

How do veterans make sense of their disengagement from traditional

exposure therapy and their subsequent engagement in a non-exposure

based intervention for Post-traumatic Stress Disorder (PTSD)? An

Interpretative Phenomenological

Analysis......................................................................................................131

2.1 Abstract..........................................................................................132

2.2 Introduction....................................................................................133

2.2.1 Combat-related PTSD........................................................133

2.2.2 Exposure therapy might not be the whole answer.............133

2.2.3 The researcher-clinician divide when applied to the

treatment of PTSD..............................................................135

2.2.4 What are the reasons for the reduced effectiveness of

exposure therapy in clinical practice?...............................137

2.2.5 How can future research help address the

effectiveness-efficacy distinction in the treatment of

PTSD?...............................................................................139

2.2.6 How can research explore client satisfaction of

therapies?.........................................................................142

2.2.7 The aim of the current study.............................................143

2.3 Method........................................................................................145

2.3.1 Design.............................................................................145

2.3.2 Interpretative Phenomenological Analysis (IPA)..............156

109

2.3.3 Reflexivity...........................................................................147

2.3.4 Epistemological Position....................................................148

2.3.5 Recruitment.........................................................................148

2.3.6 Participants........................................................................150

2.3.7 Ethical Approval and Considerations................................151

2.3.8 Development of the Interview Schedule.............................153

2.3.9 Interview Process...............................................................156

2.4 Results............................................................................................157

2.4.1 Data Analysis......................................................................157

2.4.2 Theme: The Importance of Control....................................162

2.4.2.1 Whose agenda is it anyway?..................................163

2.4.2.2 The Importance of Understanding the Rationale..169

2.4.3 Theme: The Importance of Positive Change....................172

2.4.3.1 Concerned for Recovery.......................................172

2.4.3.2 A Bright Future...................................................176

2.4.4 Theme: The Problem with Emotion................................179

2.4.4.1 Feeling unable to cope with feeling........179

2.4.4.2 Not wanting to share...............................189

2.4.5 Theme: The Importance of Relationships.......................191

2.4.5.1 Military/Civilian Divide...........................192

2.4.5.2 Feeling supported in recovery.................197

2.5 Discussion....................................................................................201

2.5.1 Overview of Results............................................................201

2.5.2 The Importance of Control.................................................201

110

2.5.3 The Importance of Seeing Positive Change......................204

2.5.4 The Problem with Emotion................................................205

2.5.5 The Importance of Relationships........................................211

2.5.6 Implications for Practice....................................................213

2.5.7 Limitations and suggestions for future research...............218

2.6 Conclusion......................................................................................222

3.0 PAPER THREE - CRITICAL ANALYSIS OF THE RESEARCH

PROCESS.................................................................................................226

3.1 Developing the Research Proposal.................................................227

3.2 Methodological Challenges............................................................230

3.3 Conclusion......................................................................................233

4.0 References............................................................................................235

5.0 Appendices...........................................................................................257

111

Paper One.

Critical Literature Review.

Distinguishing between treatment efficacy and effectiveness in Post-

traumatic Stress Disorder (PTSD): Implications for contentious

therapies.

112

1.1 Abstract.

Research psychologists often complain that practitioners disregard research

evidence whilst practitioners sometimes accuse researchers of failing to

produce evidence with sufficient ecological validity. The tension that thus

arises is highlighted, using the specific illustrative examples of two

treatment methods for post-traumatic disorder (PTSD): Eye-Movement

Desensitisation and Reprocessing (EMDR) and exposure based

interventions. Contextual reasons for the success or failure of particular

treatment models that are often only tangentially related to the theoretical

underpinnings of the models are discussed. Suggestions regarding what

might be learnt from these debates are put forward and implications for

future research are discussed.

KEYWORDS: Eye-Movement Desensitisation and Re-processing (EMDR),

Post-Traumatic Stress Disorder (PTSD), Treatment Efficacy, Treatment

Effectiveness, Qualitative.

1.2 Introduction.

In general terms, the term theory is defined as “a set of principles on which

the practice of an activity is based” (Oxford English Dictionary, 2011). For

Counselling Psychologists, who value inter-subjectivity, psychological

theories are used to inform a practitioner’s therapeutic practice and provide

“tools” that can be utilised in therapy (Moller & Hanley, 2011). Although

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the importance of theory in our profession is plain to see—it dominates our

language, informs therapeutic practice, and is a core component of any

psychological training programme—it is not the only element that

influences psychological therapy. Therapist factors such as competence

have been highlighted as having an impact on therapeutic variance

(Wampold, 2004) as have client factors such as personality and motivation

(Onwuegbuzie & Leech, 2005). Other psychologists such as Rosenzweig

(1936) and later Luborsky et al (2002), with the idea of the “Dodo Bird

Effect”, have also sought to highlight the importance of commonalities in

therapies such as a therapeutic alliance and allegiance. If one were to accept

the “Dodo Bird Effect” as a valid description of the relative merits of

different treatment models, one would have to conclude that other general

factors such as a strong therapeutic alliance and allegiance are just as

important as specific psychological models in determining treatment success

(Wampold, 2004).

Despite the regular resurgence of this idea, and regular repetition of

Rosenzweig’s (1936) phrase, “All have won so all must have prizes”,

applied psychology has accepted, to a great extent, the notion of evidence

based practice (EBP; Newnham & Page, 2010). Derived from the medical

model (Hemsley, 2010), EBP emphasises the need to find the most

successful treatment method for a particular disorder as determined by the

highest forms of evidence, the randomised control trial (RCT) and the meta-

analysis. Such acceptance leads the National Institute of Clinical Excellence

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to expend effort in ensuring practitioners have up-to-date evidence on which

to base their practice (Hemsley, 2010).

Despite a great deal of rhetoric in applied psychology regarding the

importance of evidence-based practice models, in real-world therapy

settings not all practitioners rely on such evidence when choosing and

delivering treatments (Newnham & Page, 2010). The current trend for the

adoption of EMDR as a treatment for PTSD is illustrative and will be taken

up in this paper as an example used to demonstrate a set of more general

points.

1.3 Post-traumatic Stress Disorder.

Within the treatment arena of Post-Traumatic Stress Disorder (PTSD), there

is a wealth of evidence that supports the use of exposure-based CBT for

reducing the symptoms of PTSD and its sub-groups which include combat-

related PTSD (Power et al., 2002). Such work remains topical today not

least because of the recent wars in Iraq and Afghanistan. Exposure based

interventions enjoy a sound theoretical grounding, having developed

initially from behavioural movements with the more traditional techniques

of flooding and implosion (Groves & Thompson, 1970), and later having

developed alongside both cognitive and behavioural paradigms with the

treatment protocol involving exposure to the feared stimuli combined with

cognitive restructuring (e.g. Foa & Kozak, 1986). As well as general support

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for the broad theoretical orientation, which is at root an application of basic

behavioural psychological principles, exposure based interventions for the

treatment of PTSD also enjoy sound evidence of efficacy in the form of trial

data (Foa, Dancu, Hembree, Jaycox, Meadows & Street, 1999; Foa et al

2005; Schnurr et al., 2007). In fact the research base which supports the use

of exposure based interventions in the treatment of PTSD is so vast that

some professionals are now terming it the zeitgeist of the disorder (Russell,

2008).

1.4 Exposure based CBT: The zeitgeist of the disorder.

Studies examining the efficacy of this form of treatment go back to the early

1980s and include Frank and Stewart’s (1984) investigation into the

desensitisation of female rape victims. More up to date research has

reported on the success of exposure therapy when compared to other

independent methods of treatment such as stress inoculation training (see

Foa et al., 2005). For combat-related PTSD specifically, a number of

studies report a similar trend. Research conducted by Cooper and Clum

(1989) examined the effectiveness of imaginal flooding, a form of exposure

therapy, over standard psychotherapeutic and pharmacologic approaches in

the treatment of combat-related PTSD. The evidence from this study

supported imaginal flooding in the reduction of symptoms relating to the

traumatic event, including traumatic stimuli-related anxiety (F=5.58, p<.05),

sleep disturbance (F=11.1, p<.01) and self-monitored nightmares (F=6.08,

p<.05). Exposure therapy has also been reported as more successful in

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eradicating PTSD symptoms in female war veterans specifically when

compared to person centred therapy. Schnurr et al. (2007) studied 277

female veterans and 7 active duty personnel with combat-related PTSD.

Participants were randomly assigned to either a prolonged exposure or

person-centred condition. Women who received prolonged exposure

experienced a greater reduction in their symptoms than those assigned to the

person-centred condition directly after treatment (d=0.29, p<.01) and this

difference was maintained at 3 month follow up (d=0.24, p<.047).

Despite the ascent of CBT and exposure-based therapies, and the solid

evidence base they enjoy, a range of other treatment methods for PTSD

have become popular during recent years. Several of these therapies have

been grouped together under the title of “Power Therapies”. The Power

Therapies, of which Eye Movement Desensitisation and Reprocessing

(EMDR) is an example, share one thing in common: they claim to work

more efficiently than the existing interventions for anxiety disorders

(Herbert et al., 2000). These therapies have been derided for a lack of

adequate trial data, and for lacking theoretical substance (Devilly, 2005).

1.5 EMDR: Theoretical substance.

In 1989, EMDR was introduced into the therapeutic arena as a new

treatment method for psychological trauma (Shapiro, 1989). Shapiro’s

account of its discovery describes a happy accident, and a flash of insight. It

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was not based on pre-existing psychological theory (Muris & Merckelbach,

1999), and in this respect differs considerably from exposure therapy and

CBT.

The theoretical basis of EMDR has been challenged by component break-

down studies which look to identify those mechanisms within a treatment

protocol that are necessary and sufficient to achieve the established aims

(Rogers & Silver, 2002). It would appear that where EMDR starts to

become unstuck is in its suggestion that the dual stimulation e.g. eye

movements, or finger tapping, are what makes the treatment unique and

efficacious (see Herbert et al., 2000). Most studies, when testing this claim,

have found that outcome is not dependent on the presence of this unique

aspect of the treatment protocol though these findings are not universal

(Rogers & Silver, 2002). For example, Wilson, Silver, Covi and Foster

(1996) conducted a study which sought to identify the contribution of eye

movements in the EMDR protocol. They compared EMDR to two identical

procedures which omitted the eye movement component. The results of

which indicated that the dual attention aspect of EMDR does contribute to

treatment outcome as desensitisation rates were higher in the full EMDR

treatment condition than the other two conditions which omitted the use of

dual stimulation.

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1.6 EMDR: Weaker evidence of efficacy.

When comparing EMDR to the front-runner in PTSD treatment, that of

exposure intervention, only a few studies have compared the efficacy of

these two treatments directly. For reasons of space, it is not possible to

document the results from all these comparison studies however a few will

be discussed. Ironson, Freund, Strauss and Williams (2002) compared

EMDR to prolonged exposure therapy in a sample of 22 traumatised out-

patients. Both treatments appeared successful in reducing the symptoms of

PTSD, with a larger pre-post effect size for prolonged exposure (d = 2.18, t

= 5.27, p = .002) than for EMDR (d = 1.53, t = 3.36, p = .008, ds calculated

by the current author). Ironson et al. (2002) compared the treatments by way

of a multifactorial ANOVA which showed neither treatment to be

statistically superior to the other (F=0.6, p<.82). Lee, Gavriel, Drummond,

Richards and Greenwald (2002) found similar results. In their study of 24

participants, the EMDR group improved slightly more (d = 1.87) than the

stress inoculation plus prolonged exposure group (d= 1.73), but the

difference between the two active treatment groups did not reach statistical

significance cut-offs (F =1.37, p=.29). Devilly and Spence (1999), in their

comparison study, found exposure techniques when delivered through a

CBT package, were superior to EMDR in reducing PTSD symptomatology,

and in this case the difference reached statistical significance criteria

[Λ(6,16)=.37, p < .007].

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1.7 The Effectiveness—Efficacy Distinction Applied to EMDR.

Whilst there is some promise in terms of EMDR’s efficacy from the

research noted above, even a charitable interpretation would have to

acknowledge that the evidence base for EMDR is weaker than that for

exposure therapy, with respect to PTSD. Some psychologists go much

further and describe EMDR as “pseudoscience” (Herbert et al., 2000) and

urge the abandonment of research on EMDR and similar therapies

categorised as such. We feel that such a position fails to take into account an

important distinction between treatment efficacy and treatment effectiveness

in psychological therapy.

Taking physical medicine, where the terms efficacy and effectiveness are

derived, as an accessible example: Drugs and procedures can often be

efficacious, bringing about desired outcomes due to the nature of their

chemical or mechanical properties, and yet lack effectiveness because they

are not well adopted by doctors and patients. The classic example is poor

treatment adherence due, for instance, to undesirable side effects. In medical

research, it is widely accepted that an intervention might be highly

efficacious, and yet have poor effectiveness in practice, whilst treatments of

lesser efficacy might produce moderately successful outcomes in terms of

practical efficacy (Marchand, Stice, Rohde & Becker, 2010).

EMDR enjoys high client satisfaction with regard to dropout figures and

treatment side effects (Marcus, Marquis & Sakal, 1997; Wilson, Becker &

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Tinker, 1995) and has seen a meteoric rise in the number of therapists

trained to deliver EMDR. With this in mind, it could be suggested that

EMDR might offer some advantages over exposure based therapies in

regard of various contextual factors. A number of these contextual factors

could be hypothesised to be associated with the high acceptability of, and

considerable therapist loyalty to, EMDR in light of the erstwhile acceptance

of exposure-based treatments.

1.7.1 The client experience.

It is not a new suggestion that prolonged exposure is thought to be

distressing and so is poorly tolerated by many clients (Scott & Stradling,

1997). Exposure therapies, particularly the more traditional methods of

flooding, involve the client repeatedly re-visiting the memory that they find

traumatic in an attempt to desensitise them to the feared stimulus. Pitman

and colleagues (1991) in their study which examined six case vignettes

found re-occurring complications which they believe to be “under-

recognised” in flooding therapy for PTSD. For instance they document how

this type of therapy can produce adverse consequences such as an

exacerbation of feelings relating to guilt, self-blame and failure.

Whilst some researchers such as Feeny and colleagues (2003) disagree,

arguing instead that most clients can tolerate and do benefit from exposure

based interventions, there is a good deal of commentary in the literature on

how exposure therapy is not suitable for all PTSD sufferers (e.g. Litz et al.,

2010). Client factors have been discussed in terms of treatment success for

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exposure based interventions. It has been suggested that clients presenting

with anger (Jaycox & Foa, 1996), alcohol abuse (Pitman et al., 1991),

suicidal ideation and avoidance, as measured through session attendance,

(Tarrier, Liversidge & Gregg, 2006) may affect treatment outcome.

Worryingly, Axis I disorders such as depression are often associated with

PTSD (Strachan, Gros, Ruggiero, Lejuez & Acierno, 2011) and

dysfunctional readjustment traits such as alcohol abuse are notably high in

veterans returning from war in both the US and UK (Rona, Jones, Fear,

Hull, Hotopf & Wessely, 2010; King’s Centre for Military Health Research,

2010).

Comparatively, within the United States at least, EMDR has been

recognised by The Department of Veterans’ Affairs and Department of

Defence (2004) as being less distressing than exposure therapy and suitable

for those PTSD sufferers who might not benefit from exposure therapy

(Russell, 2008). EMDR is considered more associative in nature compared

to the directive aspects of exposure therapy and it focuses on brief rather

than prolonged exposure to the traumatic memory (Rogers & Silver, 2002).

Evidence supplied by Wilson et al (1996) found that the dual attention

component of EMDR treatment is associated with relaxation in clients and

as such is useful in regulating the level of distress caused by the exposure

component of the EMDR protocol. The current evidence does not permit a

strong conclusion, but it appears that EMDR may be less distressing than

prolonged exposure, either because of the nature of the treatment or because

a specific element of the treatment has a relaxing effect.

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1.7.2 The therapist experience.

By most measures, the evidence base for exposure-based therapies,

especially exposure-based CBT is stronger, but data suggest that only about

twenty percent of practitioners who specialise in the treatment of anxiety

disorders use this type of therapy to treat PTSD (Tarrier et al., 2006). For

combat-related PTSD specifically, Fontana, Rosenheck and Spencer (1993)

in their study of 4000 Veterans with PTSD, found that exposure therapy was

used to treat fewer than 20% of this population and was the primary

treatment in only 1% of cases. Therapist fears of addressing the trauma

directly, a concern that the treatment will exacerbate the symptoms in

sufferers, and the distressing nature of the treatment are highlighted as the

main reasons for therapist reluctance in utilizing this type of treatment

(Becker, Zayfret & Anderson, 2004).

Whilst there appear to be notable difficulties in matching the acceptance of

exposure therapy from research into practice, it has been shown that when

exposure therapy is used in real-world therapy settings it is successful in

reducing PTSD symptomatology. A recent study by Tuerk et al. (2011)

recruited 65 veterans of the recent Afghanistan and Iraq wars receiving care

in a Veterans Administered (VA) Healthcare context to examine this point.

Whilst they did not use a control group, Tuerk and colleagues did

successfully manage to demonstrate that exposure therapy can be applied to

real-world therapy settings by showing that prolonged exposure was as

successful in reducing the symptoms of combat-related PTSD in this type of

setting as in Randomised Control Trails (RCTs). Whilst this is the case, the

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aforementioned utilisation rates for exposure based interventions are

concerning.

Comparatively, it would appear that EMDR is warmly received by a

substantial proportion of therapists. There is currently an international

association, conference and journal devoted to EMDR for example (Becker,

Darius & Schaumberg, 2007). For combat–related PTSD specifically,

EMDR is now being recommended as a treatment option for combat-related

PTSD in the US (EMDR Institute; Department of Veterans’ Affairs and

Department of Defence, 2004) and is frequently offered in local Military

Community Mental Health departments in the UK (Wesson & Gould,

2009).

Numerous studies have compared the dropout rates in exposure based

conditions with the dropout rates in other therapy conditions. Some of these

studies have found increased dropout rates in exposure therapy when

compared to supportive therapies for PTSD (Schnurr et al., 2007), with

others finding no association between treatment method and dropout rates

(Feeny, Hembree and Zoellner, 2003). Factors affecting dropout have also

been researched. Demographic factors (Tarrier, Sommerfield, Pilgrim &

Faragher, 2000), pre-treatment symptom severity (Minnen, Arntz &

Keijsers, 2002) and feelings of shame, anger and guilt (Jaycox & Foa, 1996)

are just some of the variables thought to influence dropout rates in PTSD

treatment.

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For EMDR, dropout rates have not been studied as extensively as they have

for exposure therapy. A cursory cross-study comparison suggests 10%

dropout rates can be expected from EMDR (Marcus et al., 1997; Wilson et

al., 1995), compared to rates above 25% for exposure therapy (e.g. Foa,

Rothbaum, Riggs and Murdoch, 1991). On the one occasion where dropout

rates for these two therapies were compared within the same study, tentative

evidence of higher dropout rates in exposure therapy is reported (Ironson et

al., 2002).

1.7.3 The EMDR Movement.

Shapiro (2002) has claimed that approximately 25,000 therapists are now

fully trained in delivering EMDR as a treatment method to clients.

Anecdotal evidence and a cursory perusal of any psychological training

bulletin board would support such a number. It has been accepted into the

National Institute of Clinical Excellence guidelines (NICE, 2012) as a

recommended treatment method for PTSD alongside exposure therapy and

is quickly gaining recognition in US and UK military settings (Russell,

2008). Alongside its recommendations for PTSD and combat-related

PTSD, it is also being more widely used in the treatment of other common

psychological disorders such as Phobias (Muris & Merckelbach, 1997) and

Panic (Feske & Goldstein, 1997), although it has not yet gained acceptance

by NICE for these disorders (Nowill, 2010). With these points in mind, few

psychologists would argue the point made by McInally (1999) that EMDR

“has grown quicker than the psychoanalytic and behavioural movements”.

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Despite the contentious issues which surround EMDR in terms of

theoretical grounding and efficacy, there is evidence to show that the

therapy is gaining quick momentum, as highlighted above. In addition to

the aforementioned intrinsic factors relating to the therapy’s processes,

some professionals have also posited a sociological explanation for its rapid

growth. In his article entitled “Power Therapies and possible threats to the

science of psychology and psychiatry”, Devilly (2005) refers to some

common social factors deployed by certain pseudoscientific therapies, of

which he includes EMDR, to explain the adherence of clients and therapists

to these therapies. With reference to these factors, Devilly (2005) refers to

the hard hitting article made by Pratkanis (1995) that puts forward nine

necessary qualities that a pseudoscience must possess so that people can

“buy into the concept”. The factors highlighted by Pratkanis (1995) include

such terms as “creating a phantom”, by which he describes developing a

concept that brings hope to something that appears hopeless. In the context

of EMDR Devilly (2004) connects this to Shapiro’s claim that the therapy

was 100% successful after one session. Something which gave other

professionals hope in the otherwise hopeless domain of treatment for such a

complex disorder.

Whilst the likely existence of contextual and social factors such as those

identified by Pratkanis (1995) and their relevance to the adoption of EMDR

as described by Devilly (2005) should be acknowledged, labelling EMDR

mere ‘pseudoscience’ may in fact exacerbate the in-group out-group

thinking of therapists trained in this tradition and further alienate them from

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a discourse on the evidence for and against the EMDR model. For applied

psychologists who place high value on the scientist–practitioner model of

research and therapy (Moller & Hanley, 2011), these strong social concepts

cannot be ignored if we want to retain our professional standing. The

question of whether a therapy is adopted for purely pseudoscientific reasons,

for contextual reasons to do with the distinction between efficacy and

effectiveness, or because of experimental evidence, goes to the very heart of

whether psychologists can truly describe themselves as scientist-

practitioners. It is crucial that EMDR and other power therapies be studied

for what they are, for what they might offer, and for how they have achieved

such popularity in such a short time, though this is no reason to dispense

with inquiry.

Other researchers too (e.g. Sikes and Sikes, 2003) have contrasted exposure

based interventions and EMDR in terms of efficacy, theoretical grounding

and effectiveness, suggesting that this relative mismatch needs to be

explained. The “wagging finger” need not be pointed at new and innovative

ideas but instead be pointed at the way in which psychological research is

conducted in general. With this in mind, it has been suggested that therapies

such as EMDR, might be better suited to a practice-based evidence (PBE)

mode of enquiry rather than from the traditional evidence based practice

(EBP) perspective (Nowill, 2010). The transition from EBP to PBE is

thought to be a worthy one as ever increasingly EBP is being criticised for

being compatible with certain modes of treatment akin to the medical model

such as CBT, and not with others (Newnes, 2007; Hemsley, 2010).

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Alongside the suggestions made for a change in how psychological research

is conducted with respect to PBE, it is also argued here that there is a need

for client-centred research to be more widely adopted in the PTSD treatment

arena.

1.8 Client-Centred Research.

For some time, a number of practitioners have been calling for an enhanced

place for the client perspective in the science of psychological intervention

(Stewart and Chambless, 2010). Such research would help us answer the

question we have posed: why are theoretically sound and efficacious

treatment methods in PTSD sometimes not terribly effective in practice?

To date, very little is known about the client experience of trauma therapy.

Becker et al. (2007) examined client preferences for exposure versus

alternative treatments for PTSD, including EMDR, in individuals with

varying degrees of trauma history. Their participants were asked to imagine

undergoing a trauma, developing PTSD and seeking treatment. Participants

showed a preference for exposure therapy over EMDR, though Becker and

colleagues acknowledge the lack of ecological validity of their findings

since their sample did not include participants suffering from PTSD, and

relied instead on participants imagining themselves in the situation.

Qualitative psychological methods, especially phenomenological ones, offer

tools to examine the client experience and generate insights into the

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efficacy-effectiveness question in an inductive manner (see Hanson, 2004).

Whilst this is the case, qualitative methods are underutilised in research.

This is demonstrated by a lack of available qualitative research published

(Rennie, Watson & Monteiro, 2002). It is suggested that this bias is due to

the traditional views that “good” research is based on falsifiable theories and

outcome measures that can be generalised to the wider population, all of

which sit comfortably within an EBP framework (Fairfax, 2008).

For the treatment of PTSD, it would appear that the research base has

followed this trend. Whilst there is a wealth of quantitative research

documenting the efficacy of treatment protocols, there is little evidence

aimed at un-picking the reasons for the efficacy/effectiveness anomalies

presented in this article. By drawing upon other research which has

documented the usefulness of qualitative enquiry by allowing a more

intricate understanding of the ingredients and processes within therapy (see

Berry & Hayward, 2004), it is suggested that this might be a worthy

transition in the field of PTSD research. This seems even more relevant

when looking at the growing appreciation, within psychology at least, that

generalised findings from RCTs are inhibited because of individual

differences found in both therapist and client (Fairfax, 2008).

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1.9 Conclusion.

The importance of finding appropriate treatment methods that can be used to

help clients presenting with the symptoms of PTSD is considerable. The

evidence base is currently dominated by RCTs where client satisfaction,

therapist burden, dropout rate and other similar factors are far from the

primary outcome measures, and are often considered extraneous. In these

studies, exposure based interventions have proven to be the gold standard,

not only because of their proven efficacy but also because of their strong

theoretical underpinnings. It has been proposed that the poorer uptake of

these treatments, as compared with EMDR in the current example, reflects a

research base which does not adequately take account of the distinction

between efficacy in research settings and effectiveness in real-world

therapeutic settings. Throughout the current paper it has been suggested that

PTSD research would benefit considerably from an increased attention to

practical effectiveness. This will require the adoption of a client-centred

research model where the client experience is central.

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Paper Two.

Research Report.

How do veterans make sense of their disengagement from traditional

exposure therapy and their subsequent engagement in a non-exposure

based intervention for Post-traumatic Stress Disorder (PTSD)? An

Interpretative Phenomenological Analysis.

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2.1 Abstract.

Exposure therapy is a proven efficacious treatment for PTSD; however its

effectiveness in real world practice is limited by high rates of premature

dropout, particularly for veterans of war. The current study aimed to

explore this anomaly by qualitatively examining how veterans make sense

of their engagement in or disengagement from PTSD treatments. Semi-

structured interviews were conducted with seven veterans who had dropped

out of exposure therapy and the transcripts were analysed using

Interpretative Phenomenological Analysis (IPA). A number of

corresponding themes were grouped together into four super-ordinate

themes: The Importance of Control, The Importance of Positive Change,

The Problem with Emotion and The Importance of Relationships. From

these findings the importance of explaining the rationales behind the

treatment protocols and the importance of teaching techniques to manage,

rather than avoid, emotions generated through therapy are discussed. The

findings may help therapists to further explore the difficult matter of

improving therapy for this client group so that dropout rates can be reduced

and engagement increased.

KEYWORDS: Post-traumatic Stress Disorder (PTSD), Combat, dropout,

engagement, efficacy, effectiveness, Interpretative Phenomenological

Analysis (IPA).

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2.2 Introduction.

2.2.1 Combat-related PTSD.

With advances in military equipment and medicine more soldiers are

surviving injuries sustained through combat in the recent wars in Iraq and

Afghanistan than ever before (Beder, 2011). Recent research suggests that

20% of serving military personnel experience psychological difficulties

relating to their deployment in war zones, with 4% reported as suffering

with the symptoms of post-traumatic stress disorder in the United Kingdom

and higher rates of between 15-20% reported for US veterans (King’s

Centre for Military Health Research, 2010; Hoge, Castro, McGurk, Cotting

& Koffman, 2004). Providing support for returning veterans and continuing

to expend effort in evaluating therapeutic methods for this PTSD cohort is

extremely topical and necessary.

2.2.2 Exposure Therapy might not be the whole answer.

It remains evident that, as a profession, we have at our disposal a highly

successful treatment method for reducing the symptoms of PTSD: exposure

therapy. Traditional exposure therapy is based on an emotional processing

model which requires clients to vividly recount the traumatic event that

caused them fear, threat of death or serious physical injury (e.g. Foa &

Kozak, 1986; Ehlers & Clark, 2000). Clients are repeatedly asked to

confront the memory of the event until their emotional responses decrease

and they can be gradually introduced to fear evoking stimuli (e.g. Foa &

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Kozak, 1986). This mode of treatment has its origins in classical and

operant conditioning paradigms and is deemed most successful when

teamed with cognitive restructuring which serves to invalidate the negative

appraisals generated by the individual from the traumatic event (e.g. Ehlers

& Clark, 2000).

Research trials which have sought to identify the most efficacious

treatments for PTSD have repeatedly reported on the positive effects of

exposure therapy in reducing PTSD symptoms (e.g. Bradley, Green, Russ,

Dutra & Westen, 2005; Bisson & Andrew, 2005; Bisson, Ehlers, Matthews,

Pilling, Richards & Turner, 2007) such as trauma re-experiencing,

avoidance, hyper-arousal and irritability (see DSM-IV-TR, 2000). In

addition, this treatment method has proven more efficacious, as determined

by randomised control trails (RCTs), when compared against waitlist

controls and other active treatments (Bisson et al., 2007).

In the domain of combat-related PTSD specifically there have been a

number of studies and meta-analyses which have reported on the usefulness

of exposure-based interventions for this population (see Bradley et al., 2005;

Schnurr et al., 2007). Exposure based interventions have proven useful for

soldiers presenting with the symptoms of PTSD in the aftermath of the Gulf

war (Yoder et al., 2012). In relation to veterans returning from the wars in

Iraq and Afghanistan, Rauch et al. (2009) found traditional exposure therapy

to be successful in reducing the symptoms of PTSD in a naturalistic setting,

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albeit through a modest sample size (N=10). Owing to the trial data and

meta-analyses of such data, exposure therapy has been accepted by the

National Institute of Clinical Excellence guidelines (NICE, 2012), as an

evidence-based treatment for all clients presenting with posttraumatic

symptoms.

2.2.3 The researcher-clinician divide when applied to the treatment of

PTSD.

Despite the supportive trial data regarding the efficacy of exposure

techniques in reducing PTSD symptoms, there is some evidence that this

type of therapy is not as successful when applied to real world clinical

populations (see Cook, Schnurr & Foa, 2004). Such a possibility ought to

be viewed in a broader context of the putative gap between science and

practice in mental health psychology. For years researchers have been

arguing that mental health clinicians do not incorporate empirical findings

into their practice. Conversely clinicians have argued that research findings

are limited because they cannot easily be integrated into everyday practice

as experimental trials do not consistently represent routine conditions

(Newnham & Page, 2010).

In the treatment of PTSD these debates seem ever-present when examining

the literature on the low utilisation rates of exposure therapy in practice (see

for an example, Becker, Zayfret & Anderson, 2004). For combat-related

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PTSD specifically it has been shown that despite the recommendations from

clinical guidelines that advocate the use of exposure based interventions for

combat-related PTSD, therapists are reluctant to utilise this therapy in

military settings (Fontana, Rosenheck & Spencer, 1993).

Exposure therapy suffers from high dropout rates, where clients have

disengaged from treatment before completing the recommended number of

sessions (Schottenbauer, Glass, Arnkoff, Tendrick & Gray, 2008; Zayfret,

DeViva, Becker, Pike, Gillcock & Hayes, 2005). There is some evidence

that this is due to the nature of therapy and not merely a confound due to the

nature of the psychological problems for which exposure therapy is most

often used (e.g. PTSD and phobia). For example, exposure based

interventions have been shown to have higher dropout rates than other

treatment modalities used for the same range of psychological problems,

such as Eye-Movement Desensitisation and Re-processing (EMDR: Power

et al., 2002; Ironson et al., 2002). In studies where participants are suffering

from combat-related PTSD, dropout rates from exposure therapy have been

reported as higher than those from supportive therapy in female war

veterans (Schnurr et al., 2007).

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Whilst the research on dropout figures from Randomised Control Trials

(RCTs) are concerning in themselves, Zayfret et al. (2005) suggest that

dropout figures from RCTs should be doubled when applied to real-world

practice. Zayfret and colleagues (2005) make this suggestion on the basis

that many participants drop out of research studies prior to randomisation

and thus propose that a significant proportion of clinical dropout is not

accounted for in RCTs. Owing to this, they studied dropout figures for

exposure-based CBT in a clinical setting and found that 72% of clients

receiving this type of treatment drop out before the end of therapy. Within

this figure many of the dropouts were reported prior to the start of therapy

but, of those that did commence exposure work, 40% dropped out during

treatment. These figures led Zayfret and colleagues (2005) to conclude that

more research needs to be conducted on factors which influence dropout, in

particular those that influence client engagement to this type of treatment.

2.2.4 What are the reasons for the reduced effectiveness of exposure

therapy in clinical practice?

There are two factors specified in the literature as having an impact on client

and clinician adherence to exposure therapy in routine settings. First,

Becker and colleagues (2004) report on clinicians’ fears of utilising this type

of therapy with traumatised clients. They identified that clinicians felt

uncomfortable using exposure therapy because of concerns that the

treatment would increase symptomatology and cause distress as the

individual goes through the process of re-living.

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Second, in terms of client adherence to exposure therapy, most research has

reported on client variables to ascertain reasons for exposure therapy

disengagement, i.e. what it is about the client that makes them dropout of

treatment. For example, Bryant et al. (2003) conducted a study which

compared the outcome measures of exposure therapy, exposure therapy

combined with cognitive restructuring, and supportive counselling.

Treatment dropouts were shown to have higher scores than treatment

completers on measures of depression, severe avoidance and catastrophic

thinking. In addition many studies show that substance misuse affects

attendance of sessions. For example, Sparr, Moffitt and Ward (1993) found

that clients presenting with PTSD and substance misuse were significantly

more likely to miss appointments than those clients who presented with

post-traumatic symptoms that were not self-medicating.

That co-morbidities might increase dropout is of particular concern

considering that alcoholism is the main psychological problem reported for

returning veterans in the UK (King’s Centre for Military Health Research,

2010). In addition there is evidence of high co-morbidity rates of

depression and anxiety with PTSD in UK populations (King’s Centre for

Military Health Research, 2010). Moreover, increased levels of anger

(Forbes, Parslow, Creamer, Allen, McHugh & Hopwood, 2008) and

masculine tendencies are attributed to this client group when discussing the

influencing factors associated with treatment engagement in US veterans

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(Hoge et al., 2004). With the recognition of such a diverse array of

associated symptoms and factors which can contribute to client dropout

from exposure therapy, some researchers are calling for a more detailed

study of the intrinsic therapeutic factors which can give rise to client

satisfaction with exposure therapy (Zayfret et al., 2005).

2.2.5 How can future research help address the efficacy-effectiveness

distinction in the treatment of PTSD?

There appears to be a clear disconnect between what is accepted in clinical

practice in the treatment of PTSD by both clinician and client, and what is

supported through research trials. The author has so far discussed a

treatment modality with excellent efficacy data from controlled trials but

reduced effectiveness in real-world practice: exposure therapy. On the other

side of this debate are those therapies that have been shown to be less

scientifically efficacious than exposure therapy but are more widely

accepted by both clinician and client in the treatment of PTSD. Eye

Movement Desensitisation and Reprocessing (EMDR) has recently been

used as an exemplar of this type of efficacy-effectiveness distinction in the

treatment of PTSD (Paper One of current Research Dossier).

EMDR is acknowledged as having a less solid evidence base than exposure

therapy (see Devilly & Spence, 1999). In addition, the explanation given by

its proponents for its mode of action i.e. the dual stimulation aspect of

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therapy, has been put to question through some component breakdown

studies that have shown client outcomes to be no poorer when this

therapeutic protocol is omitted from therapy than when it is included (see

Herbert et al., 2000). Regardless of these scientific problems EMDR enjoys

higher client satisfaction as determined by dropout rates and rapid therapist

adherence in real-world practice (Marcus, Marquis & Sakal, 1997; Wilson,

Becker & Tinker, 1999). Other therapeutic approaches which can be

compared to EMDR on the grounds of this efficacy-effectiveness distinction

are also enjoying great success at present, not least in UK charity

organisations for the treatment of PTSD. A cursory perusal of the available

treatment methods for PTSD through internet search engines would support

such a claim. One such therapeutic method that currently has no evidence

of efficacy but has high anecdotal client satisfaction is Spectrum therapy.

Spectrum therapy is a therapeutic package specifically designed for war-

related PTSD that is currently being used in UK charity organisations.

Spectrum Therapy is marketed as a non-exposure based therapy for veterans

with PTSD1 because the client is not asked to move repeatedly through their

traumatic memories with the therapist. Instead the principles behind

Spectrum therapy are based on an emotional-focussed model of treatment,2

where clients are encouraged to associate with all emotions attached to the

traumatic event, including anger, sadness, guilt, shame and fear, rather than

the details of the event itself. This distinction between Spectrum therapy 1 For the purpose of the current study, Spectrum Therapy is referred to in later sections either by name or by “a non-exposure based treatment”.2 This description is based on the researcher’s own observations; it is not used in reference to Greenberg & Johnson’s Emotionally-Focussed Therapy (EFT).

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and traditional exposure therapy seems important, not least because of the

recognised role of not only fear, but other negative emotions in PTSD such

as shame, anger, guilt and sadness (Lee, Scragg & Turner, 2001; Beck,

McNiff, Clapp, Olsen, Avery & Hagewood, 2011).

A further distinction between Spectrum therapy and traditional exposure

based therapy is that Spectrum Therapy is delivered by practitioners trained

in Neuro-Linguistic Processing (NLP), who once served in the military,

rather than psychologists. Whilst the fact that the therapy is run by non-

psychologists might be frowned upon by psychologists, it is interesting to

explore this innovation since researchers have often described this client

cohort as being mistrusting of civilians (e.g. Coll et al., 2012). It is also

recognised that NLP, like EMDR, has been labelled by some in the

literature as a pseudoscientific “Power Therapy”. A term used to describe a

therapy with no theoretical or scientific substance (see Devilly, 2005).

Whilst these points are not refuted by the current author, it is argued that

therapies which appear to enjoy high client satisfaction in the absence of

any efficacy trials could help develop our understanding of what makes a

PTSD treatment method effective in real-world practice.

2.2.6 How can research explore client satisfaction of therapies?

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Research into client experiences of therapy has, to date, mainly been

conducted through quantitative hypothesis-testing designs whereby pre-

defined categories have been used by the researcher to identify client

satisfaction of therapy (McLeod, 2001). Whilst this research is deemed

important, not least because of the expectations placed on practitioners in

the National Health Service to report on outcome measures and client

satisfaction, it is argued that qualitative methods are better suited to gather

data rich enough to allow for a more detailed understanding of the client’s

subjective experience (see Berry & Hayward, 2004). This is particularly

relevant for Counselling Psychologists who are guided by professional

practice guidelines which advocate the importance of client subjectivity

within therapy (BPS, 2009).

Very little work has been done to date to explore experiences of exposure

therapy. Of the one study known to the current author that qualitatively

explored client experiences of exposure therapy, Shearing, Lee and

Clohessy (2011) report the experiences of clients who have stayed engaged

with exposure therapy to be positive once they had overcome their

scepticism of, and fears about, engaging in the re-living process.

Investigating the experiences of those who do not drop out of exposure

therapy in this way, may help allay the fears therapists have about using this

treatment with PTSD sufferers in practice (Becker et al., 2004). Such work

however is not likely to help gain the trust and engagement of clients unless

it results in changes to the treatment model and how it is delivered (see

Becker & Zayfret, 2001).

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By exploring client reasons for dropout from a particular psychological

treatment method, we can start to gain an understanding of how these

therapies can be moulded, and better presented, to increase client

satisfaction. This could go some way in helping to bridge the gap between

what is efficacious in research trials and what is effective in therapy. This

seems particularly important in the treatment of PTSD as both client and

clinician have at their disposal, a highly successful treatment method which

is being underutilised and in some cases, not adhered to in therapy. In the

case of combat-related PTSD specifically, where high dropout rates from

exposure therapy are recorded (Erbes et al., 2009; Schnurr et al., 2007) it

seems essential that research not only look at enhancing treatment methods

that reduce the symptoms of PTSD, but also focus attention on helping

make efficacious therapies more attractive to this client cohort.

2.2.7 The aim of the current study.

The aim of the current study is to examine what therapeutic factors have led

to veterans’ disengagement from traditional exposure therapy and their

subsequent engagement in a non-exposure based treatment for PTSD. Given

that Starks and Brown-Trinidad (2007) laud the usefulness of qualitative

methodologies for this type of exploration, and with the notable lack of this

type of inquiry in the field of PTSD in the aftermath of war (see Shearing et

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al., 2011), the current research base would gain value from a qualitative

exploration into how veterans make sense of their engagement or

disengagement from specific therapies.

As the concern of the current study is not with what is efficacious in the

treatment of PTSD, but more with what factors influence engagement of

PTSD treatment, it will be interesting to look at the distinction between

efficacy and effectiveness by comparing how clients make sense of their

disengagement from a highly efficacious treatment method in PTSD, that of

exposure therapy, and their subsequent engagement in a treatment package

for PTSD which has no current evidence base: Spectrum therapy.

In the absence of any efficacy trials it will be interesting to examine what it

is about Spectrum therapy that has kept veterans, who previously dropped

out of exposure therapy, engaged in this treatment method. It is hoped that

this qualitative exploration of client experiences will add to our knowledge

of client engagement in combat-related PTSD which will aid future theory

development, and eventually lead to improvements in our existing

efficacious therapeutic methods for PTSD, such as exposure. With this in

mind, the current study is guided by the research question: How do veterans

make sense of their disengagement from traditional exposure and their

subsequent engagement in a non-exposure based treatment for PTSD? It is

believed that such an inquiry will help bridge the gap between efficacy and

effectiveness in the arena of combat-related PTSD treatment, which is

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currently a widely held concern for practitioners and researchers alike

(Becker et al., 2004; Garcia et al., 2011; Shearing et al., 2011).

2.3 Method.

2.3.1. Design.

The critical literature review for the current study has identified a gap in

existing knowledge between efficacy and effectiveness in the treatment of

PTSD. Furthermore, this gap has been explored in the introduction section

of the study in relation to veterans of war receiving exposure therapy.

Concerned with these debates, the current study used qualitative

methodology to address the research question which focuses on participants’

subjective experiences of both traditional exposure therapy and a non-

exposure based treatment package for PTSD: Spectrum Therapy. As

qualitative approaches adopt an exploratory stance (Lyons & Coyle, 2007)

and can help discover the success or failures of particular interventions

(Starks & Brown-Trinidad, 2007), it was felt that this would provide

valuable insight into clients’ experiences of therapy that have not previously

been acknowledged, particularly from the experience of veterans who have

disengaged from exposure therapy.

2.3.2 Interpretative Phenomenological Analysis (IPA).

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This research was guided by the principles of Interpretative

Phenomenological Analysis (IPA). This research method was chosen

because of IPA’s theoretical position as an inductive approach to analysis

which allows a detailed exploration of how participants make sense of their

lived experiences (Smith, 2004). In this instance, the information gathered

concerned participants’ experience of PTSD treatment methods in order to

assess what factors either helped or hindered therapeutic engagement from

exposure therapy and a non-exposure based intervention. In addition, IPA

was the methodology most consistent with the research aims when

compared to other qualitative enquiries.

Grounded theory was considered during the developmental stage of the

current research; however it was deemed inappropriate due to the focus on

social processes rather than individual experience (Lyons & Coyle, 2007),

the aim here is to take the client’s perspective. In addition, considering the

focus of the current study is on individual participant experiences of

treatment and not a desire to build up a new theory for PTSD treatment,

grounded theory was discounted from the design selection. Other

qualitative methods were considered, such as thematic analysis and content

analysis, however it was felt the interpretative aspect of IPA would help

develop a deeper meaning of participant narratives which could be used to

ascertain a richer psychological understanding of the factors which affect

client engagement in PTSD treatment. As this interpretative element of IPA

is not promoted in either thematic or content analyses, they too were

discounted from the design selection.

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A central feature of the IPA design is that the researcher analyse the data

produced from the interviews in order to make meaning of the clients’

experiences. As this can only be done from one’s own interpretations and

conceptions, it seems appropriate that the author be transparent and honest

about “one’s own perspective” (Smith, 2008).

2.3.3 Reflexivity.

The author of the current study is a 28 year old, White-British female, who

developed an interest in the research topic through her own clinical practice

as a trainee Counselling Psychologist. The author became interested in the

treatment of PTSD when working with a client presenting with the

symptoms of PTSD using exposure based interventions. The author found it

difficult to apply these techniques to a very vulnerable client who was

finding the work distressing. In response to this experience the current

author started to search out research papers which supported the difficulties

applying exposure based techniques to clinical practice with regard to

dropout (Zayfret et al., 2005) and barriers to clinician utilisation of exposure

techniques (Becker et al., 2004), looking for ways to improve her own

practice.

2.3.4 Epistemological Position.

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Willig (2008) suggests that a psychologist’s philosophical stance be utilised

not only in practice but also in research. The value system attached to the

Counselling Psychology profession which heralds the importance of

subjectivity and understanding the lived experience of people has been

incorporated into the development of the current research question. For this

reason the epistemological stance adopted for the research is one that views

the construction of reality as being based on subjective and social factors.

This constructivist framework differs from the traditional views of

positivism and empiricism which strive to find an objective reality (Lyons &

Coyle, 2007). As IPA places high importance on meaning-making from the

perspective of an individual’s personal and social contexts, it sits well

within the current researcher’s epistemological position. Furthermore

Stewart and Chambless (2010) document the importance of case study

reports in gaining clinical interest towards research findings and thus

provide an insight into how to address the recognised gap between research

and practice in the field of psychology. This seems a particularly important

consideration for the current study as there has been a proven mismatch

between evidence and practice in the arena of PTSD treatment (Becker et

al., 2004; Garcia et al., 2011).

2.3.5 Recruitment.

Participants were recruited through the founder of Spectrum therapy who

operates privately in Manchester and in UK charitable organisations across

the country who have adopted this approach to PTSD treatment (for a copy

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of the consent form provided to the founder of Spectrum therapy, please

refer to Appendix 4). Initially, the founder of Spectrum therapy informed

potential participants about the nature of the current study. From this, only

those individuals who had expressed an interest in taking part in the current

research and who had given permission for their details to be passed on

were deemed contactable by the researcher. These participants were initially

contacted by telephone where a full description of the study and their role

within it was provided. At this stage, if participants agreed to take part, an

e-mail containing the study’s information pack and consent form was sent to

them (for a copy of the participant consent form, please refer to Appendix

5).

Participants were eligible for the current study if they had been diagnosed

with PTSD, had disengaged from a course of exposure therapy in the past

and had subsequently engaged in a full course of Spectrum therapy. In

addition, as the focus of this study was to examine war veterans’

experiences of PTSD treatment, all participants needed to have served in a

military setting for at least 2 years and experienced a traumatic event within

this setting that triggered the symptoms of PTSD for which they were

seeking treatment.

2.3.6 Participants.

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A total of seven participants were recruited for the purpose of the current

study. This sample size was decided upon because of the recommendations

made by Smith and Osborn (2008) that between five and seven participants

is suitable for an IPA design. Smith, Flowers and Larkin (2009) describe

the main feature of IPA as gaining a thorough understanding of individuals’

experiences through a case by case analysis which can be restricted in larger

samples.

Through purposive sampling, IPA aims to find participants with similar

experiences or characteristics (Smith et al., 2009). The inclusion criteria,

described above, were adhered to strictly not least to ensure the

homogeneity of the sample. In addition to the outlined criterion, all

participants reported strong avoidant tendencies and problems regulating

anger before receiving any therapeutic intervention. Four of the seven

participants were self-medicating, either through use of alcohol or taking

non-prescription drugs, as a means of regulating their symptoms. No

attempt was made to restrict the gender of participants, however due to the

nature of the client group, all participants were male.

Table 1 Details of participant demographics.

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Participant Gender Age(years)

Ethnic Origin

Length of time in the service (years)

Involved in active combat

1 Male 25 White British

4 Yes

2 Male 29 Black African

9 Yes

3 Male 34 White British

12 Yes

4 Male 32 White British

5 Yes

5 Male 42 White British

22 Yes

6 Male 35 White British

13 Yes

7 Male 37 White British

9 Yes

2.3.7 Ethical Approval and Considerations.

An initial research proposal was submitted to the University of

Wolverhampton Research committee in November 2010 (please refer to

Appendix 6 for a copy of the Res20 form). On completion of minor

amendments, ethical approval was granted by the Ethics Committee of the

University of Wolverhampton, School of Applied Sciences in June 2011,

(please refer to Appendix 7).

A two-part process was adopted for consent. Potential participants were

sent an information pack (see Appendix 8) by email upon expressing an

interest to take part. The participants who responded to this email were

telephoned some days later to confirm their involvement. Once participants

had agreed to take part, a suitable time and date for the interview was

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arranged with the participant. At the start of each interview, the researcher

asked the participants whether they had fully read and understood the

information pack which had been sent to them via e-mail before verbally

outlining the nature and purpose of the study. The researcher then directed

participants through the consent form, highlighting in particular, the sections

pertaining to participant confidentiality, anonymity and their right to

withdraw. Participants were made aware that original transcripts would be

read by the research supervisors only after all potentially identifiable

information had been omitted. In line with the Data Protection Act (1998),

participants were made aware that transcripts would be kept for up to five

years in a secure electronic format that was password protected. Time was

allowed for participants to ask questions about the research before the

recordings started.

One of the ethical concerns raised at the planning stage of the study was the

vulnerability of this client group to potential distress. In line with this

consideration, participants were made aware at the point of consent that they

would not need to talk about their specific traumatic experiences, but more

their experiences of treatment and how this impacted on their symptoms. In

addition, throughout the recordings the researcher remained sensitive to the

needs of participants, and where necessary, informed them of their right to

withdraw from questions if they so wished. Debriefing sheets were

prepared for use with any participant who showed signs of distress, with

details of alternative treatment options and support organisations (please

refer to Appendix 9).

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2.3.8 Development of the Interview Schedule.

It is important when using an IPA design that the interviewees have optimal

opportunity to detail their own experience and be viewed as the expert of

their own “story” (Lyons & Coyle, 2007). For the purpose of the current

research question, the participant-centred feature of IPA was deemed most

attractive, as it allows participants to explore and describe their experiences,

something which cannot be achieved through questionnaires alone. A semi-

structured questionnaire was developed for use in the interview which

would allow the researcher to adapt the interviews for each participant

according to their accounts and thereby draw out their most relevant and

meaningful experiences.

Open-ended questions are considered the exemplary method for an IPA

design as they offer a “focused yet flexible method of data collection”

(Smith & Osborn, 2008). In order to allow for flexibility within the

interviews, semi-structured, broad ranging questions were developed by the

researcher to give participants the opportunity to reflect upon their own

personal experiences of therapy. In order to remain focused on the research

question the interviewer designed an interview schedule to address three

main areas of participant experience (see Table 2). For a copy of the full

interview schedule please refer to Appendix 10.

Table 2 A snapshot of the Interview Schedule

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Areas of Interest Example of the Semi-structured Questions

Their experiences of

life with PTSD

What was life like for you with PTSD?

Symptomatology

Effect on family and work life.

Their experiences of

Exposure Therapy

What influenced their decision to disengage from

the therapy?

How did they feel about the therapeutic

protocols/what they were asked to do in therapy?

How comfortable did they feel in the sessions?

How did they feel after the therapy sessions?

Their experiences of

Spectrum Therapy

What was it about the therapeutic method that

influenced their decisions to stay engaged in the

treatment?

How did they feel about the therapeutic

protocols/what they were being asked to do in

therapy?

How comfortable did they feel in the sessions?

How did they feel after the therapy sessions?

At the start of all recordings participants were given an opportunity to

discuss their experiences of life with PTSD. This was thought important

because in IPA there is an appreciation of adding “context” to participant

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experiences so that a richer data set can be assembled. This not only relates

to the research question, but also to the participant themselves (Smith et al.,

2009). Indeed Shenton (2004) refers to this context as a “thick description”

whereby a detailed overview of the participant is provided so that findings

may later be contextualised. For this reason it seemed important to get an

impression of client experiences before entering into therapy as it was

thought this could add some rich data pertaining to participant context

whilst also adding value to the research question.

With regard to the questions pertaining to participant experiences of therapy

direction was taken from the results of Shearing, Lee & Clohessy’s (2011)

qualitative study into client experiences of reliving in trauma focused

cognitive behavioural therapy. Whilst Shearing et al. (2011) found

participants experience of exposure therapy to be generally positive, they

allude to several factors within the discussion of their findings which relate

to participants unease with both the process of therapy and the impact of

engaging in the re-living protocol once therapy had finished. For this reason

it was thought important that non-directive questions relating to these

factors be incorporated into the current interviews.

As the current researcher was inexperienced in conducting semi-structured

interviews, it was decided by both the researcher and the researcher’s

supervisor that some initial training and role playing be incorporated into

supervision prior to any interviews being conducted. Amendments to the

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style of questioning were deduced from this supervisory input before the

researcher carried out the first of the interviews with participants. After the

first two interviews were conducted both the researcher and the researcher’s

supervisor analysed the transcripts in terms of the questioning style and

comparisons were made between the questions that could have been asked

and what participants were actually asked. This sought not only to develop

the researcher’s interview style but also to enhance the credibility of the

research study.

After analysing these initial transcripts, the original decision to include five

participants in the current study, was extended to include seven participants

to allow for a richer data set to emerge. The transcripts of all seven

interviews are included in the data set.

2.3.9 Interview Process.

A total of seven participants were interviewed in total for the purpose of the

current study. All interviews took place over Skype in order to reduce any

unnecessary anxiety for participants travelling to unfamiliar locations.

Each recorded interview lasted approximately 30-60 minutes. Participant

demographics were taken before the interview commenced. At the end of

each interview, the researcher again confirmed participant participation and

each were given the lead researcher’s contact details in case of any future

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questions. Directly after the interviews, the researcher commented on the

interview process and the initial impressions of content that emerged from

the recordings in a reflective diary aimed at increasing researcher reflexivity

throughout the data collection and analysis phases. Each interview was

followed by a debriefing session and participants were directed to the

debriefing form contained in their information pack.

2.4 Results

2.4.1 Data Analysis

All transcripts were transcribed by the researcher in a bid to familiarise the

researcher with the emergent data. Unfortunately, due to time constraints,

participants were not able to read their transcripts to check for accuracy.

Owing to this, after each transcription, the researcher listened to the

recordings several times whilst simultaneously cross-checking the

transcripts.

The data were analysed and coded in accordance with the principles of IPA

outlined by Lyons and Coyle (2007) and Smith et al. (2009). The first phase

of analysis involved the researcher becoming “immersed in the data set”

(Smith et al., 2009). As the researcher was involved in all aspects of

transcription and accuracy checks, familiarity was readily obtained. This

said the process of active engagement in the data is notably important in the

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IPA literature as it helps the researcher stay connected to the original

recordings (Shenton, 2004). With this in mind the researcher re-read each

transcript twice more before any interpretation took place.

In terms of interpreting the data, direction was taken from Smith et al.

(2009) who define three distinct categories of data coding in an IPA study:

the exploration of descriptive comments, outlined in the current transcripts

in normal font, linguistic comments, noted in italics and conceptual

concepts denoted in bold font. An example of this initial interpretation

phase can be found in Table 3.

Table 3 Example of the initial interpretation phase.

Original Quotations Interpretations. P: Well this way, the major thing was revisiting things that, places that I didn’t want to go then

Wanting to avoid his memories. “major” – highlighting the extent of the conflict.Therapy conflicted with his desire to stay disconnected.

Once the initial interpretations had been completed, the researcher re-read

the data once more to draw out the main emergent themes within the data

(see Table 4.)

Table 4 Example of how emerging themes were generated.

Emergent Themes Original Quotations Interpretations

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Conflict between avoidance and the re-living process.

P: Well this way, the major thing was revisiting things that, places that I didn’t want to go then

Wanting to avoid his memories.

“major” – highlighting the extent of the conflict.

Therapy conflicted with his desire to stay disconnected.

The emergent data for all of the transcripts were then re-analysed so that

patterns from the transcripts could be outlined (see Table 5). These patterns

were subsequently entitled “sub- ordinate themes” (Smith et al., 2009). For

an example of a participant’s table of themes, please refer to Appendix 11.

Table 5 Generating the sub-ordinate themes.

Sub-ordinate Theme

Emergent Themes

Original Quotations Interpretations

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Whose agenda is it anyway?

Conflict between avoidance and the re-living process.

P: Well this way, the major thing was revisiting things that, places that I didn’t want to go then

Wanting to avoid his memories. “major” – highlighting the extent of the conflict.Therapy conflicted with his desire to stay disconnected.

The final stage of coding involved the researcher making connections across

the sub-ordinate themes through the process of abstraction (Smith et al.,

2009). This involved generating clusters of themes based on similarity from

which larger super-ordinate themes were generated. These larger, super-

ordinate themes were then titled to capture the nature of the sub-ordinate

themes associated with this larger grouping. Owing to the nature of the

study, where participants were asked to comment on factors that both helped

or hindered engagement in PTSD treatment, polarisation (Smith et al., 2009)

was often adopted, as the factors related to each sub-ordinate theme were

sometimes discussed on the grounds of opposition. Please refer to Appendix

12 for a copy of the grand master table where all super-ordinate themes,

sub-ordinate themes and corresponding quotations can be found.

Throughout all stages of data analysis, the researcher and research

supervisor met to discuss the emergent themes and to reflect upon the lead

researcher’s interpretations of data to ensure that the researcher

interpretation was as credible and un-biased as possible.

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A total of four super-ordinate themes were identified across the majority of

the interviews, capturing within them a total of eight sub-ordinate themes (a

thematic diagram is presented in Table 6).

As the research is concerned with exploring how clients make sense of their

experiences within the respective therapies which have either helped or

hindered engagement, the themes described are all concerned with the

following research question: How do veterans make sense of their

disengagement from traditional exposure and their subsequent engagement

in a non-exposure based treatment for PTSD? This said it seems

impossible to fully contextualise the findings without summarising and

interpreting what participants chose to say about their experience of PTSD.

To this end, some of this contextual material will be presented in the hope

that it will provide a richer understanding of their experiences within

treatment.

In order to ensure anonymity throughout the research, and so direct

examples from the transcripts can be used to illustrate the points made, all

participants will be referred to using pseudonyms.

Table 6 Thematic diagram of themes.

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Super-ordinate Themes Sub-ordinate Themes

The Importance of Control Whose Agenda is it Anyway?

The Importance of Understanding

the Rationale.

The Importance of Positive Change Concerned for recovery.

A Bright Future.

The Problem with Emotion Feeling unable to cope with feeling.

Not wanting to Share.

The Importance of Relationships Military/Civilian Divide.

Feeling supported in recovery.

2.4.2 Theme: The Importance of Control.

All participants described the importance of control when describing either

their engagement in, or disengagement from, the therapeutic process. This

sense of control is concerned with the choice they felt they had in the

respective therapies and gaining an understanding of the rationales behind

the treatment protocols that they were being asked to engage in.

2.4.2.1 Whose Agenda is it Anyway?

Many participants report on the conflict between the therapeutic protocols

being asked of them in exposure work and what they wanted to do in

therapy. The majority of participants report feeling reluctant to engage in

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the re-living aspect of the treatment plan. This conflict is represented

through narratives of feeling forced to engage in the re-living process of

exposure work.

Matt: Yeah, well it was like I wasn’t in control, they were asking me to do

something that I really didn’t want to do, but I was there for a reason so I

thought well you know let’s try it. I didn’t want to do it but then again I had

to do it. It was a control thing, I had no control it was a frightening

experience (line 72)

Luke: This way, the major thing was revisiting things that, places that I

didn’t want to go then (line,115)

Ben: But when you are explaining it to a therapist kind of thing or someone

in a working environment it’s more a case of I’ve got to do this...erm...and it

becomes like a battle if you will (line 124)

These experiences in therapy seem particularly important for this group of

participants as all of them describe using avoidance as a coping mechanism

when dealing with the symptoms of PTSD. The following examples from

two of the narratives are used to illustrate this avoidant style coping

mechanism which is described by all participants, and highlights a belief

that in order to carry on with life, they need to stay disconnected from their

traumatic memories.

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Matt: I think that’s what I was doing to be fair I was just numbing myself to

come back, coz I have got to block myself I’ve got to get on with my life I’ve

got to block it all somehow (line 122)

Frank: I was running marathons and stuff, I was punishing myself to try and

convince myself that I was fine (line 32)

For Matt and Frank in particular, the belief that they must stay disconnected

from their experiences in order to carry on with life entered into the therapy

room and made them actively decide to work against the process. This

experience in therapy seemed to generate a conscious decision to disrupt the

re-living process in an attempt to re-gain control over the therapeutic

environment.

Matt: Yes I thought you know I don’t want to go here I don’t want to go

there, so I disrupted the flow (line 102)

Frank: I would stay that way until I could put a lid on it again and then by

that time I was back in speaking to her, I was thinking I really don’t want to

take the lid off this so I would tell her a different story, I just didn’t want to

visit there, I would tell her something else it doesn’t matter what it is it

could be about anything, it wouldn’t be about military it would be about my

personal life or it would be about this, it would be anything other than that,

so I avoided as best I could what really hurt me (line 88)

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For other participants feeling as though they were working to somebody

else’s agenda was reported in a different way. For one participant in

particular, the structured nature of exposure therapy left him feeling as

though the treatment was very restricted and impersonal.

Frank: it was very restricted, I felt it was restricted, this is what we do in

CBT, this is what we are trained in, this is how we take you, there was no

flexibility on how to address... or never showed itself.... the system was too

structured (line 130)

When describing how they felt in Spectrum therapy, a very different set of

narratives emerges, which relates to participants’ positive experiences in

therapy owing to a sense of choice they felt they had in the sessions.

Matt: Whereas they are not telling you.... not saying to you, you must do this

or go back into this or go back into that, it’s your choice (line 238)

Luke: like the process you know, you’re pretty much, doing all the work

yourself they are just directing you (line, 254)

Frank: They are using your language pattern...so... you’ll come up with

answers erm...no one’s telling or advising you or suggesting to you (line

164)

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For Frank and Matt, a sense of control was generated through Spectrum

therapy because they felt they were not working to somebody else’s agenda

and timescales.

Frank: By being given the space to reflect and connect with myself at my

own pace instead of being bombarded with questions about what exactly

had happened to me in the army (line 192)

Matt: I mean you’re not being told to do it, if errr...if you want to talk, you

can talk you know..... there’s no time scale on it, you know everybody’s sort

of like you know... yes go and have a cup of tea and we’ll talk about

something different, we’ll do this, we’ll do that you know it’s like yes it’s

like a great big....freedom (line 248)

For Sam in particular, Spectrum therapy was reported as feeling more

“gentle” as therapy seemed to go at a pace he felt comfortable with.

Sam: Well the colour is like it keeps you safe it makes you feel safe and if

things do get uncomfortable you can use the colour to disassociate yourself

from whatever it is that’s being found uncomfortable (line 141)

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This sense of choice and flexibility that participants felt they had in therapy

seemed to make the therapy feel individualised as all participants describe

their wants and needs being incorporated into the therapeutic process.

Frank: Yes, I guess that the amazing thing is errr the therapy is about you

treating you, not someone else forcing you to be treated their way, does that

make sense?(line 166)

Sam: Yes that was something I chose to do, but yes that was something I

suggested that I would like to do and they put it into intervention to make

that happen (line 127)

Thomas: But with Spectrum therapy you don’t go through that you don’t

have to talk about the event you can talk about a moment in time or the fear

or where the position of … where you feel the emotion you don’t.....erm

from my experience of it....it is a very gentle process which doesn’t dig into

any sort of err….. it allows you... going through a process without going

into minute detail that could be very uncomfortable it certainly was in my

case anyway, I didn’t need to go into minute detail (line 222)

Matt: Yeah, yes, they worked on a lot of things you know, but they worked

on what you wanted to work on (line 302)

In addition, feeling in control of the therapeutic process in Spectrum therapy

seemed to generate positive feelings about the therapist and the therapeutic

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relationship, where an equalizing of power was described between client

and practitioner.

Matt: It was basically comradeship everybody seemed to be on the same

level you know because they were trained therapists it didn’t mean that they

were above you...they were on the same level as you (line 224)

Researcher: And what affect does that have on you do you think feeling on

the same level? (line 227)

Matt: Well its great isn’t it, you’ve got the control (line 228)

Researcher: Right, ok....so it makes you feel in control does it?(line 229)

Matt: Yes, they have the control and you have the control. (line 230)

Sam: It was like the approach he used I felt very much equal to the person

who was treating me (line 99)

2.4.2.2 The Importance of Understanding the Rationale.

For some participants it would appear that developing a thorough

understanding of the usefulness of the therapeutic protocols involved in

exposure therapy was an important factor that was missing from this therapy

as they discuss feeling ambivalent towards the value of the therapeutic

protocols in their recovery. Throughout these narratives there is a strong

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sense that the participants did not understand why re-visiting their traumatic

memories was necessary.

Ben: it was like putting me back in there you know ...so close your eyes get

back in there.... and why would I want to do that you know?(line 40)

Matt: Erm...basically to discuss obviously your army career, sort of like

traumas that you have (line 60)

Researcher: Right, how did you experience that process?(line 61)

Matt: I mean to me it was like opening up old wounds that I , I wouldn’t

say I had pushed to the back of me mind because they’re always there but

it’s like I wanted to block them out. I don’t....I wish I could wake up one

morning and somebody’s drilled a hole in my head and took these things out

(line 62)

For another participant, ambivalence is presented through a sense of

frustration aimed at the therapist for “repeatedly” asking him to talk about

his experiences. This participant describes his mental model of how therapy

should work being at odds with that of the therapist. Through this

description the participant portrays a belief that avoidance is a necessity in

his recovery. Owing to this, the reader is left with the impression that not

only is he confused about the benefits of the re-living process, but that he

also believes engaging in such process will hinder his recovery.

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Gary: Yes I mean just asking what I had been through, all the time asking

about what I had experienced....and erm.... I just thought it was all totally

irrelevant to what...... I was trying to get well, in myself like......I become

resentful of counselling for years I just thought what a waste of time you

know (line 62)

For Ben, being informed of the therapeutic protocols involved in exposure

therapy seems particularly important as he felt that the therapist was asking

him to disclose his traumatic experiences for their value instead of his own.

This is described when he talks about how he experienced the internal

nature of Spectrum Therapy. An illustrative example of this point is

documented below; however there are many examples in Ben’s narrative

where he refers to feeling as though he was engaging in the re-living process

for the benefit of the therapist rather than for himself. This is strongly

conveyed in the following narrative where he connects being asked to re-

live his experiences with a morbid curiosity in his therapist.

Ben: what (name of Spectrum therapist) seemed to do was like... so like ask

me to pick a certain memory, when you felt this... ok then.... now he didn’t

want you to openly discuss this....see that’s privately for you with the

feelings and that, so which was a great thing, I thought to myself wow these

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aren’t asking me to go into details as if they are not just after a gory story

kind of thing you know (line 102)

In congruence with this point, two other participants described the

importance of being informed of the rationale behind the therapeutic

protocols in Spectrum therapy in helping them engage and feel more

comfortable with what they were being asked to do. This seems to give

participants a sense of control over the process which subsequently gives

them confidence to engage in therapy.

Thomas: Well it wasn’t difficult...erm I mean I understood why I was doing

these things that I was being asked to do so I felt ok in doing them you know

(line 216)

Matt: why are they asking me to think of something nice (line 194)

Researcher: Yeah (line 195)

Matt: I don’t think I’ve had anything nice happen to me in a long time, but

they explain to you why you are doing it which was important...well it was

for me anyway to erm...have somebody explain to me why this was

important (line 196)

2.4.3 Theme: The Importance of Positive change.

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The next super-ordinate theme that was identified relates to the importance

of seeing positive change in therapy. When discussing the factors that

influenced their engagement within therapy, all participants either spoke of

a concern for their recovery or seeing a bright future as factors which

affected their engagement.

2.4.3.1 Concerned for recovery.

For some feeling unable to cope with the re-living process of exposure

therapy was connected to a fear that they would be unable to cope with the

after effects of engaging in this therapeutic protocol once out of the session

and thus their recovery would be impeded.

Matt: You are trying to get your head together on your own and if I had all

that messing around with my head again it was just like here we go again

(line 188)

For the majority of participants they reported being concerned about

engaging with the actual re-living process itself because it felt too

overwhelming for them. For these participants this was represented through

a feeling that the re-living process was all consuming.

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Sam: Well it was like you were still there, I just remember every time I had

to talk about it I used to get the intensity of being there again (line 62)

Thomas: For very short periods she had me in the moment of

being...in...and erm....even now I have to just have to you know......(line 176)

The researcher observed that some participants spoke about how the reliving

process impacted on their ongoing lives by bringing the trauma to the

forefront of their minds.

Luke: it just revisited everything and brought it all back to the surface so

then when I was coming away it may have made it worse (line, 113)

Ben: Erm...more or less...because it was putting it right at the front of your

mind, I mean it’s always there like I say these intrusive thoughts are always

there (line 40)

Many participants explained how, when they had engaged in the re-living

process, they saw no positive change in their symptoms which contributed

to their decision to leave therapy. The following example is illustrative of

many a narrative.

Sam: that’s why I eventually stopped going to the therapy it wasn’t making

things better (line 89)

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Some participants report frustration in exposure therapy as they became

concerned for their recovery after the sessions. This was identified in the

narratives through descriptions of feeling worse after the re-living process.

Luke: Were all based on that , so I keep reliving what my dreams are about,

what you know, what other things are effecting, what flashbacks are

happening etc (line, 94)

Researcher: Huh, yeah ok (line (95)

Luke: I’d come out of there 10 times worse you know (line 96)

Sam: I would be more upset sometimes I could go there and I would end up

being in a worst state afterwards sometimes (line 68)

For others a sense of desperation was felt as they began to lose faith in their

recovery after engaging in a session of exposure therapy.

Frank: Like I would go and feel worse after the treatment and it was like

I’m not getting better at what stage do I tell her that this is not working for

me what else can I have... this is not working (line 114)

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Earlier on in Frank’s narrative he talks about why he felt his recovery was

impeded in exposure therapy.

Frank: I felt great trust with the lady treating me and we had a good

rapport going, the only thing was as I have said before it’s trauma focused

and again it was re-visiting a story I have told that many times it has

become completely impersonal and a void of me (line 102)

Researcher: Right so why do you think it had become a void of you? (line

103)

Frank:...because if I felt or...if I was to be associated with what I was saying

I would become very ill again and I just didn’t want to be there, so it was...it

was... so what, and I wasn’t resolving anything we were just going over old

ground of 20 years (line 104)

This shows that in therapy, Frank made a conscious decision to stay

disconnected from his memories in exposure work because of a fear that

connecting with the memories would impede his recovery. This fear of an

impeded recovery seems so strong that it overrode the strong therapeutic

relationship he had developed between himself and his therapist.

2.4.3.2 A Bright Future.

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Conversely, many participants reported seeing positive change after

Spectrum therapy which encouraged them to continue with the process. For

many, the importance of seeing quick change in therapy seemed to prove as

motivation to actively engage in the treatment protocols.

Ben: then once you notice that it is working you can’t wait to go on and do

some more and see what else you can dispel kind of thing (line 162)

For Thomas, shifting the focus from his past experiences to his future

seemed to generate positive change and encouraged him to stay engaged in

Spectrum therapy.

Thomas: Well it erm....it changed me from being in a position where I was

helpless to actually being in a position that made me realise that actually

there is a future there’s a way forward so that obviously...erm...the... the

positive change was there so it helped (line 226)

This is something that seemed particularly important for Thomas when

examining how bleak his future appeared to be when he was suffering with

PTSD.

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Thomas: Oh yes massively you have to remember that PTSD it

destroys....errr.. it makes your life miserable, anything that can take you

from a place where you are wanting to take your own life to a place where

you can see a future and actually you have got something to work with is

incredible in my eyes that is something you have got to take note of (line

228)

Interestingly, this sense of a lost future pervades the majority of narratives

when participants talk about their experiences of life with PTSD. It remains

to be seen whether this is an important factor in contributing to client

engagement in Spectrum therapy, given the hope participants describe after

engaging in these therapeutic protocols.

In addition, when discussing the positive effects of Spectrum therapy, a

feeling of empowerment was related to the brighter future participants felt

was now possible. Some participants spoke about this feeling of

empowerment after Spectrum therapy when talking about how confident

they felt in their abilities to get better autonomously without the help of a

therapist.

Sam: I was always willing to submit to the treatment... always went into

every session wanting to find whatever I was looking for to enable me to get

better. I didn’t find that until I learned Spectrum, it wasn’t something that

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was told to me or it wasn’t something that was suggested to me, it was

something I figured it out on my own (line 123)

Frank: It’s helping you because you know that actually you can put in place

what you were taught when you were away (line 168)

As many participants described feeling like a failure when suffering with the

symptoms of PTSD, this theme appeared central to their experience of

Spectrum Therapy.

Matt: Oh yes, yes I mean I tried to commit suicide (line 12)

Matt: I tried that a couple of times and bloody failed at that as well (line 14)

Thomas: I thought I was showing massive signs of weakness (line 108)

Gary: We had heard about the Americans in the Vietnam War and that erm..

but we just pushed it aside and thought aaah just typical Yanks you know

and PTSD if you like was deemed as being weak (line 18)

2.4.4 Theme: The Problem with Emotion.

The third super-ordinate theme relates to a strong narrative that features in

all the transcripts which documents participants’ desires to stay

disconnected from their emotions in exposure therapy. This super-ordinate

theme is broken down into two sub-ordinate themes. The first sub-ordinate

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theme is concerned with fearing the consequences of connecting with their

emotions in therapy. The second sub-ordinate theme under this category is

more akin with a fear of sharing their emotions with another.

2.4.4.1 Feeling unable to cope with feeling.

The first factor under this super-ordinate theme which seemed to effect

participation in exposure therapy relates to a feeling that they could not cope

with the negative emotions generated from exposure therapy. In several of

the narratives, there is an underlying sense that participants view their

emotions as debilitating and therefore they want to avoid connecting with

them. The following narratives once again depict an avoidant style coping

mechanism that the majority of participants report as affecting their

engagement in exposure therapy. For the majority of participants they not

only report wanting to avoid the memories of the trauma as described in the

earlier theme of “whose agenda is it anyway?”, but also a desire to avoid

connecting with the emotions attached to the traumatic memories.

Thomas: I actually find I can talk about it now whereas before it would have

triggered the same emotions and issues I had when I was thinking about the

incident itself (line 170)

Ben: Well not good coz I don’t think they were addressing it, it was a case

of you had to talk about it. I think they were doing it with the idea that if

you talked about it, it shouldn’t bother you, and I thought hang on a minute

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I can’t talk to you about it, coz I know that, that them feelings are still there

with the memories (line 54)

Matt: I could feel myself shaking you know and..... I’d cry I would cry for

want of a better word and I couldn’t understand why I was crying. I just

didn’t want to be there to be honest (line 70)

Frank: ….it felt… it was easy to talk about if I stayed disconnected, you

know without opening myself up to how I was feeling (line 126).

When discussing his experiences of life with PTSD, Frank reports how his

emotions took him away from the professional person that he once was. As

he did not want to lose this sense of Self, he felt he had to disassociate from

his emotional world.

Frank: I was able to become two people I felt these emotions and these

things inside, I put them to one side and tried to stay professional in what I

did (line 16)

Interestingly, when talking about their positive experiences of Spectrum

therapy, many participants describe how the therapeutic protocols involved

in this therapy changed the fearful relationship they once felt they had with

their emotions. It would seem that identifying and connecting with their

emotions in this therapy was encouraged which in turn allowed them to

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change their preconceived conceptions that their emotions should be

avoided.

Frank: This was my own piece of learning that Spectrum Therapy helped me

to uncover....that my emotional world was not something to be afraid of

(line 190)

Frank: Yes...I managed to get an understanding of what had happened and I

found that I didn’t need to be fearful anymore...I didn’t need to separate

myself in two...I found I could connect with my emotions around what

happened without being afraid (line 188)

For Gary his recovery was concerned with changing his relationship with

his emotions which in turn seemed to change his relationship with the

trauma.

Gary: for me you know I guess it was a bit like shifting something spiritually

you know what I mean it was like, it was ok just to feel that way. It’s

changed my outlook on i....t it’s changed my thinking on it, it’s like what I

went through, erm.. that I don’t have to be fearful of it any more I don’t

have to be angry about it anymore erm....(line 76)

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For Gary, it would appear that he took comfort in the Spectrum therapist’s

ability to be able to contain his anger which in turn gave him encouragement

to express his anger instead of avoid it.

Gary: I mean they would tell me that it was ok to feel it as erm...as it was

all about feeling my emotions so I felt it was ok to express my anger (line

84)

Creating an environment where Gary felt able to express his anger without a

fear that any negative social consequences would ensue seems particularly

important when examining the impact anger had on his Social Self before

entering into treatment.

Gary: I would start to get angry you know and may be smash the house up

and get ………. you know that..... and then that’s who you resemble to them,

then I realised that there was no point talking about it (line 36)

Generating an understanding of one’s emotions and the ability to manage

the Self were noted by several participants as the most useful part of staying

engaged in Spectrum therapy. This emotional awareness for many of the

participants seems to be one of the most influential factors in their recovery

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as they report feeling in control of their emotions instead of their emotions

being in control of them.

Ben: Now what the erm...Spectrum therapy did was make sure you are in

control of your emotions, they teach you to deal with the emotions (line 178)

Matt: Yeah, I think the emotions will always be there but...they... they are

more controllable now (line 261)

Researcher: OK so you have control over them now? (line 262)

Mat: I have yes, I’ve feel as though I’ve got control over me (line 263)

Sam: It’s like you can read your emotions....it’s a fresh start for you (line

137)

Another significant factor identified in the majority of the narratives

associated with the sub-ordinate theme of feeling unable to cope with feeling

relates to how the re-living element of exposure therapy generated specific

un-wanted emotions for participants. For these participants shame, anger

and guilt were highlighted as hindering their engagement in exposure work.

Ben: Erm...no I wouldn’t say it was easy as I said it was emotional you have

to go through it but there was a lot of guilt inside me (line 48)

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It would appear that for two participants, this feeling of guilt relates to their

military experiences which seem to be all consuming after engaging in

exposure therapy. For these participants it feels as though exposure therapy

left them feeling all consumed with their war-related behaviours.

Ben: Yeah because a lot of your actions and a lot of the

way...erm...personally myself after treatment I would sit wallowing on

what....what have you done and the anger, and think that was horrible (line

146)

Matt: Well it like you feel bad because you’re faced with all the bad things

that have gone on and it makes you not want to erm....open yourself up

anymore do you know what I mean? (line 146)

For others, the presence of anger was believed to be generated from the re-

living process. For those that reported anger as consequential to the re-

living process of exposure therapy, this was described as influencing their

decision to disengage from the therapy. Owing to the way these participants

describe their anger, the reader is left with the impression that this emotion

is viewed by the participants as unacceptable and is subsequently something

that needs to be avoided.

Luke: they had quite a few no shows as well coz I was getting so badly

worked up after it (line, 100)

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Sam: Well not for me, no, I just used to feel uncomfortable and a lot of the

time I’d get angry (line 87)

Gary: It wasn’t long because, like I say I got slightly angry with her and the

fact is I thought this is a load of rubbish and I stopped going (line 46)

The negative consequences of getting angry in the therapy sessions seems

particularly important to participants as the majority discussed the impact of

anger when suffering with PTSD in terms of it taking away their sense of

identity. For Sam, Thomas and Ben this is highlighted through their

descriptions of how they felt anger changed the relationship they had with

themselves.

Sam: I was so angry I was taking it out on my family, I mean, sometimes I

would get up and I wouldn’t be able to feel comfortable where I was in my

own skin (line 32)

Thomas: I would be..... very unreliable, I would be very volatile,

and....trying to exist in...well normality didn’t really seem to exist in any, in

any, spectrum, I have tried to,.... I remember..... sort of trying to make sense

of anything was very difficult at the time, being very aggressive very angry

(line 6)

Ben: Well, it’s like you’re...you’re having like an out of body experience,

you can see yourself erm..... you can see yourself doing things and losing

your temper, losing your anger, and everything and it’s as if you are

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standing at the side and watching it happen and you are powerless to do

anything you know (line 2)

In addition to guilt and anger, five out of the seven participants reported

how the presence of shame made it difficult for them to engage in the re-

living process of exposure therapy. For some, shame seems to be generated

by the re-living process itself. For Sam, this was true because he felt he was

acting strangely in therapy as a result of fear. For Sam this fear seemed to

be generated by the realism of the re-living process.

Sam: It’s all fear driven a lot of things, is from fear, its fear...I mean...

anyone would do strange things when they are scared it does sort of induce

erratic behaviour if you’re scared (line 62)

Sam: See every time you tell it you get the same burst of emotions that you

had when you were there, the main thing is you’re not there so the shouting

and the erratic behaviour is now making you look quite like there’s

something wrong with you (line 70)

For three participants shame was generated through exposure therapy

because their suffering was brought to the forefront. For these participants

there seems to be reluctance in engaging with this suffering because they

attribute this to a sign of failure.

186

Frank: after normal therapies that I have known in the past I have felt dirty

and hateful and horrible and didn’t like myself because how I have allowed

all this to happen to me, how have I allowed myself to be so ill (line 172)

Ben: Erm....I had a horrible sense of loss because errr I was proud when I

was doing the job itself and I didn’t think it had affected me until

afterwards, when they obviously were putting me back in there and having

to go through.... you got all those horrible feelings again, you know the

shaky inside the total uncomfortableness, and total restlessness (line 44)

For Thomas in particular this theme is particularly poignant as he describes

a significant sense of failure when he was suffering with the symptoms of

PTSD as he placed high expectations on the Self to be able to cope. Thomas

clearly wanted to stay disconnected from his suffering as he attributes this to

a defected Self. This defected Self seems to be highlighted in exposure

therapy and subsequently contributes to his disengagement from treatment.

Thomas: What a waste of time you know and I remember thinking as well, I

remember thinking was this real.... was my mind playing tricks, I was

actually quite lost. I remember thinking was this making me ill by doing

this and then convincing myself that there was nothing wrong with me (line

160)

187

Researcher: Right and did that make it difficult for you when you were in

the therapy?(line 161)

Thomas: Well yeah like I only went to 4 or 5 of those sessions, because in

my own mind at the time I remember thinking I am stronger than this and

that (line 162)

For one participant, shame seemed to feature more as a pre-existing self-

judgement that his military experiences were bad and therefore could not be

shared. This is distinct from the other narratives where shame was

experienced as a consequence of the re-living process itself. For Gary, it

would seem that pre-existing shame attached to his military experiences

inhibited his ability to talk to the therapist in the re-living process of

exposure therapy.

Gary: Yes it was I mean you have got to look at.....like all the stuff I have

done and seen to tell someone about it it’s pretty difficult you know what I

mean?(line 92)

For Gary it would appear that sharing his experiences means he will need to

share what he sees as a horrible secret relating to his actions in the military.

For this reason he found the internal nature of Spectrum therapy particularly

useful as he was able to keep his experiences hidden from the therapist

which then seemed to encourage engagement in the therapeutic protocols.

188

Gary: before, when I was asked to talk about my experiences I felt

ashamed....like what I had done, was bad...but in Spectrum I didn’t have to

talk about my problems (line 107)

2.4.4.2 Not wanting to share.

The importance of not having to share their military experiences with the

therapist in Spectrum therapy is not only featured in Gary’s narrative, but in

the majority of the other narratives also. Participants reported how the

internal nature of Spectrum therapy helped them connect with their

emotions. The narratives associated with this point state the importance of

an internal process in Spectrum therapy, where participants were not asked

to share their experiences with the therapist, as helping them feel able to

cope with emotion. In not having to verbalise their emotions participants felt

more able to cope with the therapy as it would seem that for the majority,

keeping their emotions in their heads had been a long standing coping

mechanism. In Spectrum therapy participants report being able to keep this

coping mechanism intact as they do not have to verbally express their

emotions. This feels safer and more manageable to the majority of

participants.

Sam: you are not verbalising it you can cope with it you can’t take away the

emotions or you know, change anything that’s ever happened, but you can

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cope with it because you are not verbalising it, the emotions are not being

shown so you are able to go through it without the intensity, without any

emotion being present really (line 111)

Frank: ... I again... I could never express what was going on inside me, but

with Spectrum it’s all about emotion, it all about what you see what you

hear, what you feel and it’s all held in your head. Because it’s about that

you can give yourself the permission to go there and erm...be involved with

what happened (line 186)

Luke: So that you’re ok...you might be going through the situation when you

felt, you know, different emotions or whatever but you, you don’t as such

have to speak out about it you know (line, 177)

These accounts suggest that participants felt unable to cope with their

emotions in exposure therapy because of an over concern of how the

therapist would view the emotion and subsequently the Self. This concern

seems to be eliminated in Spectrum therapy because the participants were

not required to share their emotions with the therapist. This seems to

provide an element of safety in treatment as the participants do not feel they

are exposing themselves to judgement.

2.4.5 Theme: The Importance of relationships.

Participants described two main factors associated with Spectrum therapy

that enhanced their therapeutic relationship and subsequently encouraged

them to engage with the therapeutic process. This super-ordinate theme has

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therefore been broken down into two sub-ordinate themes which relate to

Military/Civilian Divide and Feeling Supported in Recovery.

In the majority of narratives, participants describe a difference between how

they view their relationships with civilians and people who are ex-military.

This difference seems to be generated from the strong bond formed between

serving members when in combat. This camaraderie is reflected in

participants’ descriptions of an unparalleled level of trust and understanding

experienced between themselves and other veterans of war. This level of

trust and understanding, for the majority of participants, is absent from their

relationships with civilians.

In addition many participants describe feeling supported by their Spectrum

Therapist as positively affecting their therapeutic relationship. This sub-

ordinate theme will be discussed in relation to participant experiences of the

continuing availability of Spectrum therapists and a clearly expressed

normalisation process where participants felt connected to their therapist on

the level of military experience and PTSD symptom comparison.

2.4.5.1 Military/Civilian Divide.

Many participants described the importance of the therapist being a veteran

in Spectrum therapy in helping them feel connected to the practitioner. This

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connection seems to be generated by a shared understanding of military

experiences between the participants and the Spectrum practitioner.

Luke: Yeah because it was ex-forces erm, who were delivering the treatment

so obviously the understanding was there, it helped then you know (line

167)

Gary: When I got there I met this team and some of them were ex-soldiers

which made me feel a bit more comfortable (line 64)

Researcher: Why did that make you feel comfortable do you think?(line 65)

Gary: Well...immediately I knew that they would understand me and what I

had been through (line 66)

For some, feeling understood also seemed to generate trust in the

therapeutic relationship.

Matt: They understand what I am going through I understand what they are

going through and I trust them to be honest (line 38)

Sam: Yes that massively helped I’ve got to say that straight away you know

you are talking to a mucker you’re talking to someone who knows the

terminology and I think that’s the basis of the... the trust (line 107)

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Other participants went further with this point by placing trust and

understanding as the main reason for their engagement in therapy. This is

summed up in Matt’s narrative when he talks about how he would feel if his

therapist didn’t understand him.

Matt: Frustrated, despondent, uncomfortable, you name it, angry........ it’s

everything (line 222)

Thomas also believes trust to be a central part of treatment engagement,

particularly in trauma work as he felt he was exposing himself to his

therapist in this type of therapy.

Thomas: they are asking you to re-live and going through processes which

are very personal to you, I know for a fact that if I haven’t engaged with

someone on a level I am comfortable with and I trust that individual I would

go no further, you know my own defence mechanisms would kick in (line

144)

The importance of building a trusting relationship where the participants felt

understood seems to be particularly important as the majority of participants

described feeling unsafe to discuss their experiences with civilians for fear

that they will judge them.

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Ben: And as well when I feel...errr...if you’re trying to talk to a civilian,

somebody who has not been through it they might feel you are being

farfetched kind of thing, like you are exaggerating the story or something

like that so you clam up and just tell them the basics erm....but you can tell a

soldier the full story because he is getting right in there he is with you, you

know that’s how I feel (line 78)

Matt: but it’s just something there you know straight away that your

thoughts are safe with that veteran (line 284)

This “them and us” mentality seemed to enter in to the therapy room for

Gary and impacted on his relationship with his therapist.

Gary: because she was a civilian and the fact is when you’re trying to tell

someone about what you have been through its like....you know.... you get

the impression do they believe me (line 32)

This description by Gary offers an insight into his thought process about the

severity of this military/civilian divide as he feels his military experiences

are so far removed from everyday life that his therapist might not believe

what he is saying. Interestingly, other participants allude to this point when

talking about their difficulties re-integrating back into society when they left

the military, with the majority reporting feeling a being a breed apart from

civilians.

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Matt: I always distanced myself from people....I don’t know, whether I

couldn’t trust them, whether.....I always felt as though people were like

looking at me staring at me, talking about me.... paranoia basically (line 24)

Sam: It’s finding your way back into society, I didn’t see how I was going to

do it (line 46)

Gary: You’ve got to remember when you are soldier you are trained to kill

aren’t you so....but your mind says that you can’t think that way because it

goes against the grain in human nature unless you’ve got psychotic

problems or whatever in you, schizophrenic you want to go out or you’re a

serial killer that’s something totally different. But like when you have been

trained to be aggressive and kill someone and then go back into Civi Street

and try to re-adapt to normal life...I guess a lot of ex-soldiers would

struggle with that you know (line 98)

This divide between ex-military officers and civilians seems to be

strengthened by the necessary camaraderie developed between themselves

and other military officers for survival whilst serving.

Ben: It was like a code, an unwritten code amongst all the forces that, you

know when you are serving you know, whether it be a ships company,

whether it be in barracks or whether it be out at war, you know that you

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have got your mates and you trust them like you do your brothers, not like

anybody else (line 86)

It would seem for some of the participants that being in the military and

having such a level of trust with other military personnel made it difficult to

trust people who have not been in the forces. This seems to impede the

therapeutic relationship as participants feel it is more difficult to trust a

civilian than an ex-military officer.

Luke: Coz like when you are going through stuff as close to the wall that’s

causing you problems you want to kind of trust the person that you have to

revisit that stuff with, but I didn’t trust him you know (line, 125)

Researcher: Oh right, why do you think that was?(line, 126)

Luke: Well, I mean basically, he hadn’t experienced what I had, had he?

(line, 127)

Matt: If you got a civi doing that I wouldn’t open up like I did, I wouldn’t

have done what I did you know, but because it was ex-squaddies I trusted

them, it’s just one of those things if I met an ex-squaddie walking down the

street today within 5 minutes I would be talking to him and I would trust him

(line 210)

2.4.5.2 Feeling supported in recovery.

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The second factor identified in the majority of participant narratives which

connects to the super-ordinate theme, The Importance of Relationships,

relates to feeling supported in their recovery. For some participants this

seemed to be represented by the fact that they did not feel alone in their

recovery. This was mainly generated through the structure of Spectrum

therapy and the availability of Spectrum therapists.

Luke: Yeah, so its erm, it’s as though if, if something’s brought up then you

know that the following day it can be talked through and helped with and

that you don’t have to wait 6 days or however long to, to revisit the problem

(line 295)

Gary: but the process of being there continually for 4 days helped me

connect (line 113)

Researcher: Right in what ways do you think it helped you connect?(line

114)

Gary: Well I knew it was ok to speak about my anger because I wouldn’t be

left dangling with it for days on end....it could get resolved (line 115)

These narratives give the impression that some of the participants felt alone

in their recovery in exposure work and that often this would prevent them

from engaging in the process because they felt unsupported. This seems to

be an important feature for Ben that he felt was missing in exposure work.

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Ben: they brought them all to the top and you talked about them and then

that’s it, they say ok then thanks very much I’ll see you in a week’s time and

so I say ok I’ll see you later (line 154)

For one participant in particular the weekly structure of exposure work

actually felt quite damaging as he describes going through unhelpful

processes in between therapy sessions.

Frank: don’t leave the person hanging on. Don’t leave them hanging on

because by the time... like I said if someone’s been made to visit a trauma

they have then got to wait another week to re-visit that trauma then that’s

another week of self-blaming and then trying to disassociate yourself from

what has happened ermm..You know what I mean?(line 178)

Researcher: Yeah, did that experience in between sessions, affect how you

viewed therapy Frank?(line 179)

Frank: Yeah definitely, I mean after the hour, that’s it your time is up but

the problems don’t stop there you know (line 182)

There is also a sense that some participants felt supported because of the

consistency of the Spectrum therapists. Such descriptions pervaded both

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Ben’s and Luke’s narratives when they talk about the positive effects of the

therapists’ persistence and availability in their recovery.

Ben: They don’t give up on you... you know what I mean?(line 138)

Luke: Well...you’ve always got in your head you can go back if you wanna

you know, if you need a little bit more, but, which at the minute I haven’t so,

and it’s been a while so (line 326)

The second way some participants documented feeling supported was

through being given hope in their own recovery. For Ben and Matt this

hope seemed to be generated through the comparisons between their own

and their Spectrum therapist’s experiences of PTSD and the military.

Ben: So I thought right all these people here have been that angry ex-soldier

that I have been for twenty years so I thought you’ve got to give this a bash

(line 96)

Matt: But anyway after like the second day it was sort of like …obviously

talking to a couple of the lads that were doing the therapy they were ex-

squaddies and I saw how they were and obviously talking at night after the

therapy had finished you know staying in the place just talking to them in

general about what they had been through and it was like how come you are

like that now? And it started to all make sense (line 166)

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Comparisons between the clients themselves also seemed to encourage

engagement in the process as their experiences of the therapy could be

normalised. This seemed to encourage engagement as they felt connected in

the uncertainty of the therapeutic experience. There is a sense through these

narratives that participants felt able to cope with the effects of treatment

when their experiences were normalised by others who were also engaged in

the therapeutic process.

Matt: I had a little chat with another guy on the course one night and said

what do you think of this, he said I really don’t know what it is, but

something’s happening, so we basically said to each other well you know

lets go for it then (line 200)

2.5 Discussion.

2.5.1 Overview of results.

The current study had one aim: to explore how veterans make sense of their

disengagement from traditional exposure therapy and their subsequent

engagement in a non-exposure based intervention for PTSD. The findings

from the current study indicate that there are a number of similarities in the

experiences of the participants as represented through the shared themes. In

addition, there seems to be shared themes across opposing aspects of

treatment experience which were noted as either helping or hindering

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participant engagement in therapy. For example, under the super-ordinate

theme The Importance of Control, participants reported a lack of control in

exposure therapy as hindering their engagement, whilst a higher degree of

control was reported in Spectrum therapy as helping them feel safe engaging

in therapy. These themes and the corresponding oppositions will be

discussed in relation to the current literature with implications for

therapeutic practice and future research highlighted.

2.5.2 The Importance of Control.

One of the main reasons why participants in the current study decided to

disengage from exposure therapy was because they report experiencing a

conflict in therapy as their avoidant style coping mechanisms were being

challenged. This is recognised as being a particularly difficult balancing act

in therapy for the trauma therapist. Whilst it is important for therapists to

facilitate an environment where the client feels in control of the processes

being asked of them in order to develop a feeling of safety, the therapist also

needs to stay mindful that adhering to a client’s avoidant behaviours or

cognitions could maintain their symptoms (Lindy, Wilson & Friedman,

2004).

For participants in the current study re-visiting memories that they wanted

to forget seemed anathema to them and in some cases impacted on the

therapeutic relationship, as participants felt the therapist had control over

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their treatment plan. This subsequently seemed to generate feelings of

frustration or left participants questioning the therapist’s intentions for

asking them to engage in the re-living process. Whilst a perceived lack of

control has been highlighted as affecting dropout from exposure therapy in

clients suffering with PTSD after a motor vehicle accident (Taylor, Fedoroff

& Koch, 1999), until now this finding has not been supported by research

on PTSD resulting from other event types, such as combat.

In Spectrum therapy participants reported a more client-driven experience

where their wants and needs of therapy felt accepted and validated. This is

mainly discussed in relation to a sense of freedom participants felt they had

as they were not asked to repeatedly revisit their traumatic memories with

the Spectrum practitioner. This finding agrees with Murphy, Rosen,

Thompson, Murray & Rainey’s (2004) suggestion that clients with PTSD

are often ambivalent about changing the coping strategies that maintain their

symptoms. For combat-related PTSD in particular, addressing ambivalence

about changing a veteran’s coping mechanisms is recognised as being an

important first step in the treatment plan of this client cohort, as they often

present with strong beliefs that their coping mechanisms are functional

rather than dysfunctional (Murray et al., 2004). The current findings would

extend this point further by suggesting that dropout can occur if this

ambivalence is not addressed. This seems particularly true for those

veterans who strongly believe that avoidance is imperative to their survival.

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Participants in the current study report feeling unaware of the benefits of the

therapeutic processes involved in exposure work and how this impeded their

engagement. This lack of understanding seemed to contribute to their

frustrations in exposure therapy as they were being asked to engage in a

process which went against their internal model of coping. For this reason it

seems that gaining an understanding of the rationales behind the protocols in

exposure work was an important aspect of therapy that was missing for

participants. This finding was surprising given that one of the outlined

components of exposure therapy is the presentation of the overall treatment

model, including rationales and goals (Foa & Rothbaum, 1998). This said,

with increasing pressures for treatment methods to be delivered in a timely

and cost-effective format, this whole process is advised to take no longer

than one session (see Cook et al., 2004). For the client cohort in the current

study, it would seem that a continuing narrative on the usefulness of the re-

living protocols was vital to their engagement in such a fear-evoking

process. This point is further supported by the majority of participants

explicitly mentioning the importance of continually and repeatedly being

informed of the benefits of the therapeutic processes involved in Spectrum

therapy.

2.5.3 The Importance of seeing Positive Change.

Participants spoke of their concern that if they were to engage in the re-

living process of exposure therapy their recovery would be impeded. This

seems to be related to a fear that negative consequences would ensue if they

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were to engage in the re-living aspect of exposure therapy. Participants

report a fear of their symptoms getting worse or feeling overwhelmed by the

re-living process as reasons for their disengagement from exposure therapy.

Such fears have been noted in the literature as being “common appraisals”

made my PTSD sufferers (Ehlers & Clark, 2000). Contrary to cognitive

theories of PTSD, which postulate that a client’s fears of facing their trauma

memory will be worse than the reality of doing so (e.g. Ehlers & Clark,

2000), participants in the current study report their fears being actualised in

therapy. These findings, whilst contrary to the standard cognitive model, are

not entirely unpredicted. Indeed caution regarding the use of exposure

therapy appears in the literature on the grounds that the re-living process can

be an overwhelming experience for clients (see Hembree et al., 2003).

Some participants reported experiencing a worsening of PTSD symptoms

during re-living, a finding which confirms the fears expressed by clinicians

as a reason for not adopting this type of therapy in real world practice (see

Becker et al., 2004). Conversely, seeing quick change in their

symptomatology in Spectrum therapy contributed to participants’ continued

commitment to this therapy. Seeing change in Spectrum therapy gave

participants a feeling of empowerment and hope for the future as they

started to realise that their suffering could be altered. This finding is

important to consider in line with not only the current participants’ feelings

of a lost future when describing their experiences of life with PTSD, but

with this being present in PTSD sufferers in general (Rauch & Foa, 2006).

With some research showing that PTSD symptoms worsen before reducing

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after exposure therapy (e.g. Shearing et al., 2011), and with findings which

document a gradual decrease in PTSD symptomatology from exposure

therapy (e.g. Speckens, Ehlers, Hackman, & Clark, 2006) it would seem

important for the exposure therapist to be transparent and discuss this

potential outcome with the client throughout therapy before potential

dropout occurs.

2.5.4 The Problem with Emotion.

All participants discussed having a maladaptive relationship with their

emotions and how this impeded their engagement in exposure therapy.

Participants report not only wanting to avoid the traumatic memories

themselves but also the emotions generated through therapy. In the PTSD

literature, emotions such as shame, anger, guilt and sadness are frequently

identified as impacting on PTSD sufferers (Lee Scragg & Turner, 2001).

Researchers who have supported the presence of emotions, that extend past

the predominant emotion of fear in PTSD (Foa & Kozak, 1986), have

criticised the exposure model on the grounds that moving through the

traumatic memory can heighten emotions such as shame, guilt and anger as

the client becomes more exposed to the event and the associated feelings

attached to the trauma (Pitman et al., 1991). This seemed to be a feature for

participants in the current study as they report on the presence of these

specific emotions when discussing the influencing factors associated with

dropout from exposure therapy.

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For participants in the study there seemed to be a fear of feeling as they felt

unable to cope with the negative emotions generated through exposure

therapy. This sits comfortably with the findings by Price, Monson, Callahan

and Rodriguez (2006) that a “bi-directional relationship” between emotional

functioning and PTSD is evident in this client group. Price and colleagues

(2006) discuss how a fear about experiencing strong emotions and a concern

about controlling one’s reactions in response to emotions in therapy, may

impact on the client’s successful completion of PTSD treatment.

In relation to the findings from the current study, participants report being

overly concerned with their reactions in therapy. This was identified in

participants as a feeling of shame in response to viewing their fear reactions

as strange and erratic. In addition, participants also report feeling ashamed

to admit they were suffering with the symptoms of PTSD in therapy.

Participants describe difficulties associating themselves with their suffering

because they attribute this to a sense of a failure. Indeed this finding is not

restricted to the current study with many papers reporting on the effects of

shame, and “the fear of retaliation”, as affecting veterans’ decisions to seek

help for their post-war symptoms (Hoge et al., 2004). What is interesting

from the current study however, is how this sense of failure affected

engagement in therapy. For one participant in particular, his reactions in

therapy seemed to disrupt his internal model of the Self as someone who is

strong and who can cope with adversity. Unable to associate the Self with

weakness, the participant decided to disengage from the therapeutic process

which was highlighting this perceived sign of weakness. Whilst the role of

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shame is reported in the literature as being present in the initial stages of

PTSD treatment (Jakupcak & Varra, 2011) to the current author’s

knowledge this has not, until now, been extended to dropout in combat

veterans receiving exposure therapy.

The presence of anger was identified in the current study as having an

impact on participant engagement in exposure therapy. In the majority of

cases, the presence of anger after sessions was considered the main reason

for dropout. Whilst it is not a new suggestion that veterans’ seeking therapy

for PTSD also present with high levels of anger (e.g. Forbes et al., 2008), it

is suggested here that high levels of anger may result in premature dropout

from exposure therapy. This seems to be consequential to participants

viewing the emotion as unacceptable. For participants in the current study

who discuss the negative impacts of anger on their Social Self when leaving

the army, one can start to understand why getting angrier after exposure

sessions contributed to their decision to disengage from therapy.

In addition, participants in the current study report feeling worse after

exposure therapy. They attribute this to feeling consumed with their

harmful actions in the military as they moved through their trauma

memories. In the current study the description of “feeling worse” was

interpreted as guilt. Guilt is recognised in the literature as being associated

with PTSD, although to a lesser degree than fear which is referred to in the

“formation and maintenance of the disorder” (Lee, Scragg & Turner, 2001).

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Guilt has been shown to increase during exposure therapy (Pitman et al.,

1991). For combat-related PTSD it has been argued that this construct has a

more significant impact on treatment outcome than in other PTSD client

groups. It has been suggested by Litz et al (2009) that guilt be more heavily

recognised in war related PTSD therapies owing to the nature of combat

where veterans often experience, or are actively engaged in, situations

which go against their moral compass of what is humane. Indeed

participants in the current study report the presence of guilt throughout the

re-living aspect of exposure therapy and how this then contributed to an

increase in depressive style cognitions once therapy had finished. With

reference to the current findings where participants report an increase of

guilt as influencing their decision to drop out of exposure therapy, it would

seem crucial that future research take note of the presence of guilt, not only

in impeding outcome of treatment but also when examining the effect it has

on client adherence to treatment in this PTSD cohort.

It has been shown through the foregoing discussion that participants were

reluctant to engage in exposure therapy because it highlighted negative

unwanted emotions which they wanted to avoid. Interestingly, participants

felt more able to engage in Spectrum therapy which, as a therapeutic

method, explicitly encourages the recognition of emotions attached to the

traumatic event. Not only did participants stay engaged in this treatment

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method, they report gaining recognition and understanding of their emotions

to be the most useful aspect of Spectrum therapy.

What seemed to aid participants’ willingness to connect with their emotions

was a faith that the Spectrum practitioners would be able to contain their

emotions within therapy. In addition some participants report on the

importance of being explicitly informed that experiencing negative

emotions was acceptable within therapy. In conjunction with the literature,

this finding is congruent with a “staged approach to PTSD treatment”

(Cloitre, Koenen, Cohen & Hyemee, 2002). Such an approach suggests that

exposure techniques should be offered alongside other therapeutic concepts

from different therapeutic packages to help improve client engagement.

Becker and Zayfret (2001) advocate the use of Dialectical Behavioural

Therapy (DBT) to help retain client engagement in exposure for instance.

DBT utilises concepts such as validation, mindfulness and the dialectic of

acceptance and change in relation to a client’s relationship with their

emotions (Linehan, 1993). If the findings of the current study are found to

generalise, such an approach could help clients presenting with similar

difficulties stay engaged in exposure therapy by equipping them with the

relevant skills needed to stay with their emotions instead of avoid them. The

findings of the current study could therefore be used to expand on the

recognised importance of acceptance in general psychological wellness

(Hayes, Strosahl & Wilson 2012), by tentatively suggesting that increasing a

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veteran’s acceptance of emotions might encourage adherence to exposure

therapy.

Alongside this recognition is the importance of the internal nature of

Spectrum Therapy in encouraging participants to connect with their

emotions. Participants in the current study identified the benefits of not

having to disclose their emotions to their Spectrum practitioner as helping

them connect with their emotions. This finding adds weight to the presence

of external shame associated with emotional expression in males (see

Cusack, Deane, Wilson & Ciarrochi, 2006) as participants seemed more

willing to acknowledge their emotions when they were not required to

disclose their emotionally laden experiences with their practitioner.

2.5.5 The Importance of Relationships.

The importance of developing a strong therapeutic relationship between

client and therapist is noted in the literature as being a central feature of

client engagement in exposure therapy (Cloitre et al., 2002). For participants

in the current study, the development of a trusting, emphatic relationship

seems to be developed through a shared understanding of military life

between themselves and the Spectrum therapy practitioners. Conversely,

when describing their experiences in exposure therapy, participants describe

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a concern that civilian therapists will not understand their military

experiences and may in fact judge them for these experiences.

In the literature this military/civilian divide is recognised as a consequence

of the severity of military experiences, where serving officers are often

exposed to situations that are so far removed from everyday civilian

experiences that they feel disconnected from society once leaving the

military (Litz et al., 2009). This seems to be the case for participants in the

current study as they describe how the military environment felt like a

family unit with unparalleled levels of trust formed between themselves and

the other veterans. In their relationships with civilians they describe this

camaraderie as being absent and report struggles fitting into civilian life.

For some participants in the current study a perceived lack of understanding

from their civilian therapist seemed to impede the formation of trust in the

therapeutic relationship which subsequently impacted on their willingness to

talk about their experiences in therapy. Given the recognition by participants

that they felt misunderstood by civilians and with the acknowledgement by

some that they feared judgement from their civilian therapist and were

already ashamed of their military experiences or indeed their reactions

within therapy, this divide might provide an explanation for why

participants were reluctant to talk about their experiences in therapy: for fear

of being shamed further. This finding has implications for the role of shame

in the development of a trusting therapeutic relationship particularly for

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clients who view themselves to be a breed apart from their therapist as they

fear this lack of understanding will lead to negative judgement. With the

recognition that shame can affect expression of symptoms, a willingness to

reveal painful emotions and help-seeking behaviours (Gilbert & Proctor,

2006) and with the recognised role of shame, particularly in combat-related

PTSD (Litz et al., 2009; Bruner & Woll, 2011), it seems important that this

military/civilian divide be explored further in relation to shame and the

effect this has on therapeutic engagement of veterans receiving exposure

therapy.

Feeling connected to the therapist, and indeed the other clients engaged in

Spectrum therapy at the level of military experience, seemed to provide

participants with hope in their own recovery as their experiences of therapy

could be normalised. This normalisation process subsequently motivated

participants to engage with the therapeutic protocols involved in the therapy.

This finding supports other research which highlights the positive influence

of a group programme in helping increase veterans’ motivation to engage in

therapy (see Erbes et al., 2009).

In relation to the set-up of Spectrum therapy, participants highlight the on-

going availability of their Spectrum therapy practitioners over the four day

treatment programme as encouraging disclosure of their problems. This

structure, which differs from the weekly sessions offered to participants in

exposure therapy, seemed to generate a feeling of safety as participants

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described feeling reassured that if they were to disclose their problems, they

would get resolved.

2.5.6 Implications for Practice.

Counselling and Clinical Psychologists are able to work with clients

presenting with the symptoms of PTSD in accordance with NICE (2012)

guidance on the treatment of PTSD in adults and children. The difficult

nature of engagement for veterans throughout exposure therapy (see Erbes

et al., 2009; Garcia et al., 2011) warrants consideration by both Counselling

and Clinical Psychologists on how clients can be supported through this

efficacious treatment for PTSD. It has been highlighted that the most

favoured mode of scientific enquiry (e.g. objective, quantifiable research)

has proven useful in identifying an efficacious therapy for reducing PTSD

symptoms. This said there is still a gap in our knowledge. This gap relates

to the effectiveness of PTSD treatments in clinical practice as researchers try

to explain the high dropout figures reported for exposure therapy.

Clinical practice guidelines for Counselling Psychology specifically

describe the profession as being concerned with the subjective nature of a

client’s symptoms or experiences and distinguish between Clinical

Psychology professions on these grounds (BPS, 2009). Following Berry and

Hayward (2011) who report on the usefulness of qualitative modes of

enquiry to explore such an anomaly, the current study aimed to explore the

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subjective reasons for veterans’ disengagement from exposure therapy and

their subsequent engagement in a non-exposure based treatment for PTSD.

As the findings of the current study are based on the salient themes of seven

veterans, it is not possible to demonstrate that the results are applicable to

other populations. This said it has been recognised by Stewart and

Chambless (2010) that practitioners are inclined to relate the findings of the

single case study to their own clinical work if they see similar

characteristics between their clients and those represented in the research.

From the standpoint of a Counselling Psychologist, having awareness and

understanding of these unique experiences could therefore prove useful

when working with veterans presenting with similar characteristics and

symptoms in their clinical practice. Owing to this some important though as

yet tentative considerations for clinical practice emerged from this study.

From the findings of the current study, it is evident that participants

enjoyed, and found it easier to engage in, a process which seemed to be

more in-keeping with their avoidant style coping mechanisms. In the face of

considerable and growing evidence of the psychologically salutary effects of

acceptance and the damaging effects of avoidance (e.g. Foa & Kozak, 1986;

Hayes, Wilson, Gifford, Folletee & Strosahl, 1996), as a profession we

cannot advocate avoidance in the treatment of PTSD. Instead what seems to

be an important aspect of treatment, particularly from the experiences of

participants in the current study, is the importance of facilitating an

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environment where the client feels in control of the therapeutic protocols

being asked of them and equipping them with the tools to manage the

emotions generated by therapy.

It is suggested by Foa and Rothbaum (1998) that clinicians delivering

exposure therapy remember the importance of facilitating a collaborative

relationship where both client and therapist mutually agree on when, where

and how to apply exposure techniques. The findings from the current study

would support such advice. Participants seemed to engage more readily in a

process which they felt was flexible and where they felt in control of the

therapeutic process. Flexible approaches to exposure work are available for

therapists (e.g. talking, writing or listening to a recording of the traumatic

event) and could be used as a means to help increase client control over the

therapeutic process and reduce resistance to exposure techniques

particularly with veterans who present as highly avoidant.

The findings of the current study suggest that therapeutic engagement in

exposure therapy could be increased through a continual narrative on the

importance of the therapeutic protocols and their usefulness in reducing

symptoms. Whilst informing our clients of the rationales behind exposure

therapy is documented as an initial stage in the treatment plan (Foa &

Rothbaum, 1998), it may be that this is not emphasised enough, particularly

for clients who present with strong avoidant styles of coping. In this

instance it could prove useful for exposure therapy to take a lead from other

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psychological treatments such as EMDR and Acceptance and Commitment

Therapy (ACT) where detailing the model of treatment and the benefits of

such a model for specific symptoms, is recommended in the first few

sessions of treatment (Shapiro, 1995; Hayes et al., 2012).

It has been suggested by Becker and Zayfret (2001) that prefacing exposure

treatment with emotion regulation skills for clients with PTSD might

improve client engagement. The findings from the current study would add

weight to this previously un-supported statement, particularly for clients

presenting with PTSD symptoms in the aftermath of war. Where

emotionally laden experiences are accessed and often expressed in exposure

therapy, having skills to manage these emotions so veterans do not feel

overwhelmed and are therefore less likely to avoid their emotions may

prove vital in treatment adherence. This is seen as important for the

participants in the current study as anger, guilt and shame seemed to affect

their engagement in the re-living process.

Adopting emotionally-focussed treatment packages within exposure

therapy, for example, anger management skills (Jakupcak et al., 2007) or

compassionate mind training for shame (Gilbert & Proctor, 2006) could

provide clients with the necessary skills to help change their avoidant

reactions to such affective states. It is suggested, for participants in the

current study at least, that this modification could have increased their

tolerance of exposure techniques. This finding seems particularly important

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for combat-related PTSD specifically as often this client group is recognised

as viewing emotional expression as a sign of weakness (Litz et al., 2009).

Finally, it is evident from the findings in the current study that participants

feel there is a clear cut divide between people who have served in the

military and civilians. This divide is connected to a belief that civilians,

including their civilian therapist, would not understand their military

experiences because they themselves had not witnessed such devastating

events. In the current study this had an effect on the development of trust in

the therapeutic relationship and in some cases led to participants fearing

judgement from their therapist for having such experiences.

With this point in mind, it might prove fruitful to examine the role of self-

disclosure in the therapeutic context. Whilst there is disagreement in the

literature on the usefulness and indeed the relevance of a therapist’s self-

disclosure in therapy (Forrest, 2010), it is suggested that this could have a

positive impact on the development of a trusting relationship between

veterans and their therapists. For those therapists who have broadly

traumatic experiences or who have previously worked with veterans

therapeutically, such disclosures could help challenge the belief that their

civilian therapist will not be able to comprehend their experiences.

Alternatively, when veterans feel that their experiences of war are so far

removed from the everyday experiences of their therapist, not explicitly

having to recount their traumatic memory seems to be beneficial. Internal

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investigations as featured in Spectrum therapy or focusing on brief segments

of the trauma network as featured in EMDR (Shapiro, 1995) may therefore

prove a worthy addition to exposure therapy to help improve its practical

effectiveness.

2.5.7 Limitations and suggestions for future research.

One of the main criticisms surrounding the usefulness of qualitative studies,

particularly those such as IPA which utilise relatively small sample sizes, is

that the results cannot be generalised to the wider population (Smith et al.,

2009). However this is not to say that the results from idiographic studies

are not useful to both researchers and practitioners. It is suggested by

Shenton (2004) that the data from idiographic methods, such as IPA, are

best understood within the boundaries of client characteristics and their

situations to enhance the transferability of findings from research into

practice. This therefore allows the reader to decide whether their client’s

characteristics in practice match those of the participants in the study and

therefore whether the results can justifiably be transferred to their work with

that client. In order to enhance the transferability of findings from the

current study the researcher incorporated questions into the interview

schedule pertaining to the participants experiences of life with PTSD before

moving onto questions about therapy.

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In addition, qualitative methodologies can be useful when studying an

under-researched area of psychological enquiry, where generating

hypotheses may be particularly difficult (Smith et al., 2009). The

explorations from idiographic methods can give direction to future research

by providing areas of interest which can be further explored either in

different environments or from different methodological orientations

(Shenton, 2004). For instance the findings of the current study could be

built upon by either quantitatively analysing the effects of the current

themes on client engagement to PTSD treatment or by recruiting a different

PTSD cohort such as those affected by rape or road traffic accidents to

assess if similar qualitative themes arise.

Three out of the seven participants had gone on to train as Spectrum

practitioners after completing Spectrum therapy. It could therefore be

argued that these participants were motivated to enhance the desirability of

this therapy. Whilst this possibility cannot be discounted, the researcher

was not able to detect any distinction in the narratives between those who

had, and those who had not decided to give back to the therapy from which

they had benefited. One way of minimising this limitation would be to

compare the experiences of veterans who have dropped out of exposure

therapy but who have subsequently engaged in another treatment delivered

through the National Health Service, such as EMDR. With comparisons of

EMDR and Spectrum therapy being identified on the grounds of a less solid

efficacy base and reduced theoretical substance when compared to exposure

therapy (as discussed in Paper One), it would be interesting to see if similar

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qualitative themes depicted in the current study also emerged from this

comparison.

One of the criteria for inclusion in the study was that participants had a

diagnosis of Post-traumatic Stress Disorder at the time of receiving

treatment. The researcher did not receive any confirming information of

their diagnosis, but instead relied on self-reports and participants’ referral

for exposure therapy, as confirmation of their diagnosis. In light of this, the

current researcher aimed to qualitatively examine the participants’

symptoms and experiences of PTSD symptoms before focussing on their

experiences of therapy. All participants described having symptoms

consistent with PTSD criteria as outlined by the DSM-IV-TR (2000), which

include flashbacks of the trauma, avoidance and irritability. A full clinical

assessment for the purposes of the current study would have been neither

feasible nor appropriate.

The current study relied on participants giving recalled experiences of both

therapies. For two participants, who had received exposure therapy a few

years ago, this recall was often described as “difficult”. With this in mind, it

is possible that for these participants in particular, their experiences of

exposure therapy may have been affected due to the passing of time. In

addition, Worthen and McNeil (1996) identify a possible bias in

retrospective evaluations in psychological enquiries, as recall of past

experiences may be evaluated negatively based on evaluations of

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participants’ current needs instead of their needs at the time of receiving

help. With these points in mind it would be useful for future explorations of

treatment experience to be conducted with participants who have recently

dropped out of exposure therapy but are subsequently engaged in another

therapy for PTSD to help limit the potential distortions that may occur over

time.

Finally, it has been suggested by Becker and Zayfret (2001) that exposure

based interventions would be better adhered to by clients if therapy was

prefaced by emotion regulation skills. The findings from the current study

would support such a claim as all participants found it difficult to accept and

stay with emotions such as anger, guilt and shame when engaged in

exposure therapy. The current study therefore suggests that future research

may want to examine whether an integrated form of treatment (i.e. exposure

teamed with emotion regulation skills) for combat-related PTSD is useful in

increasing client engagement to exposure therapy.

2.6 Conclusion.

The aim of the current research dossier was to respond to the gap in the

current literature which documents a clear distinction between efficacy and

effectiveness in the treatment of PTSD and combat-related PTSD. This

distinction between what is deemed useful from research trials, and what is

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deemed useful in actual clinical settings, is a common problem in more

general areas of psychology (Fairfax, 2008). For Counselling and Clinical

psychologists in particular, whose professions adopt the scientist-

practitioner model of care, this is a particularly significant problem as

routinely and consistently the use of evidence based practices in clinical

settings is encouraged (Newnham & Page, 2010).

The distinction between research efficacy and practical effectiveness has

been demonstrated in the current literature review through a comparison of

two popular PTSD therapies: exposure therapy and EMDR. Whilst both

therapies are deemed to be popular they are so for different reasons.

Exposure therapy dominates on the grounds of theory (e.g. cognitive and

behavioural paradigms) and is favoured through clinical outcome trials,

whereas EMDR appears more popular with clients and therapists in practice.

The review suggests that certain therapeutic factors pertaining to both

exposure therapy and EMDR may have an impact on client engagement and

therapist utilisation which have not yet been adequately explored through

the conventional mode of evaluation e.g. the randomised control trial.

Support for a more exploratory mode of enquiry using qualitative research

methods to further our understanding of the client experience of therapy has

been previously supported in the treatment of psychosis (Berry & Hayward,

2011). In the arena of PTSD treatment, where there is a recognised

distinction between treatment efficacy and effectiveness, the current review

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has called for a more client-centred exploration to help explain such an

anomaly (see Paper One of the current Research Dossier). It is suggested

that this type of research enquiry could help uncover strategies to improve

client tolerance of exposure therapy and thus reduce the fears highlighted by

clinicians for not using this treatment method in practice (see Becker,

Zayfret & Anderson, 2004).

Such a suggestion has been adopted by the current research project which

set out to explore how veterans make sense of their disengagement from

exposure therapy and their subsequent engagement in a non-exposure based

intervention for PTSD: Spectrum therapy. Spectrum therapy was deemed to

be a useful therapeutic approach to study because like EMDR, it too differs

from exposure therapy on the grounds of efficacy and effectiveness.

Moreover, anecdotally, a high proportion of clients receiving Spectrum

therapy had previously dropped out of exposure interventions delivered

through the National Health Service (NHS).

One of the more significant contributions to our understanding of PTSD

therapies made by the current research has been to increase our knowledge

of why veterans themselves believe they disengaged from exposure therapy.

Up until now, the research base has mainly centred on a quantitative

exploration of dropout which usually attributes client variables and co-

morbidities as the reason for dropout from PTSD treatment (Zayfret et al.,

2005). Whilst useful, such analyses can distract from proactively examining

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how therapies can be moulded to suit client need (Murphy et al., 2004). No

work has previously been conducted on client reasons for dropout from

exposure therapy, neither generally, or with veterans of war.

The current research has suggested that less efficacious approaches to

treatment may in fact be able to help develop those therapies which are

highly efficacious but are not particularly effective in practice. By

recruiting participants that have disengaged from exposure therapy but who

have also engaged in another, more novel therapeutic intervention for

combat-related PTSD, the current study has been able to identify therapeutic

factors which participants themselves ascribe a causal role in relation to

their engagement in, or disengagement from PTSD therapies. Such factors

may be able to help further our understanding of what makes a therapeutic

approach to PTSD treatment effective in practice.

Based on the findings from this research the following preliminary

suggestions for increasing veterans’ adherence to exposure therapy could be

useful for Counselling Psychologists and other mental health professionals

working with this client group in clinical practice:

Facilitating a collaborative environment where the client feels in

control of the therapeutic processes being asked of them.

Giving a repetitious account of the usefulness of techniques (e.g. re-

living) throughout the therapeutic protocols.

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Prefacing exposure techniques with emotion regulation skills.

Being mindful of the military/civilian divide and the potential effect

this may have on the development of a therapeutic relationship.

Normalising therapeutic and military experiences throughout the re-

living process.

Whilst the outcomes from this research are tentative as they are based on

limited samples, they pave the way for confirmation in future research.

Such explorations are needed if the gap between efficacy and effectiveness

in the treatment of PTSD is to be bridged.

Paper Three

Critical Appraisal of the Research Process.

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3.0 Critical Appraisal of the Research Process.

3.1 Developing the research proposal.

Discovering that a requirement of the doctoral portfolio was to devise an

original research project that contributed to the existing psychological

literature was, at first, quite overwhelming. There had been several years

between the completion of my undergraduate degree and the start of the

Counselling Psychology Doctorate and, given the speed with which research

progresses in this field, I was not confident that any idea I had would be

original. This meant that when I first contemplated my research project, I

reverted back to my default setting and looked to be told what to do. I

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started, in a haphazard fashion and with no clear sense of what I wanted to

do, by looking at the limitations of other studies. The process left me

frustrated. Although academically I understood the potential for further

study in some of the areas I looked at, the topics gave me neither the drive

nor the passion that would be required to undertake such a significant piece

of research.

It was the dual element nature of professional Counselling Psychology that

led to the breakthrough and to the conception of my research proposal. At

the same time that I was looking for answers and ideas in the limitations of

other people’s research, so too was I experiencing challenges in my clinical

placement. A client that I was working with therapeutically was finding it

difficult to engage with the recommended treatment method for PTSD.

From this practical experience I began to witness the limitations of routinely

applying therapies with the highest level of efficacy into my clinical work.

This began my fascination with the efficacy/effectiveness debate in

psychological therapy which subsequently featured in many of my academic

assignments. Through exploration of the existing literature on this debate, I

was beginning to notice that other researchers were documenting this

distinction, particularly in the arena of PTSD, and combat-related PTSD

treatment (e.g. Zayfret et al., 2004; Erbes et al., 2009). After a discussion

with my research supervisor on this topic I began to search for therapies

within the field that might help explain this divide, i.e. therapies that were

not as efficacious as exposure therapy, but that were showing promise in

clinical practice.

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Whilst looking for alternative therapies for PTSD, I became aware of

Spectrum therapy, which is marketed as a non-exposure-based intervention

for combat-related PTSD. This therapy appeared to suitably relate to the

efficacy/effectiveness distinction. It had not previously been researched but

was, at least anecdotally, proving to be successful in keeping clients

engaged with therapy up to completion. From my experiences in practice,

my subsequent literature searches on the research/practice divide in PTSD

therapies, and through recognition that other, more novel therapies such as

Spectrum were proving popular with clients, my original research idea was

conceived. This proposal included interviewing clients to determine why

they had disengaged from exposure therapy but had remained engaged with

Spectrum therapy. I decided to focus my research on client experiences of

therapy as the available research explained client dropout rates from

exposure therapy by focusing on client factors (Sparr et al., 2003; Van

Minnen et al., 2002; Bryant et al., 2003). Through my own clinical practice,

and whilst writing my critical review paper, I became more aware that this

explanation may be somewhat limited and that other variables, pertaining to

therapeutic experience could also influence dropout (see for support Berry

& Hayward, 2011).

Although the potential to undertake this research excited me and I was

confident of its value, I had reservations about how experienced academics

would view a thesis on a subject that had little previous academic scrutiny.

In addition, I was becoming aware, through more regular contact with

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Spectrum therapy that a high number of veterans were actively seeking out

this treatment method. Owing to my aforementioned reservations and my

increasing awareness of client demand for this therapy, I decided to include

another aim for my research: to study quantitatively, the success of

Spectrum therapy in reducing the symptoms of PTSD. On reflection this

idea was a goal too far. Certain factors throughout the development of my

research rendered this additional goal neither desirable nor achievable.

As I became more immersed in the literature which outlined the

efficacy/effectiveness distinction in PTSD treatment (please refer to my

critical literature review), I began to notice the valuable contribution my

qualitative study would make in this field. I became more excited by the

prospect of starting to help bridge the gap between what is deemed effective

in practice and what is efficacious from research trials. In addition, the

cohesive nature of the portfolio, with the recommendation that all individual

parts must make up a complete whole, led me to re-evaluate the decision to

include the quantitative section of my research. I wanted to honour my

original idea of conducting a piece of research which would aim to help

improve existing therapies (i.e. exposure) on the grounds of practical

effectiveness, and thought the addition of a quantitative section which aimed

to test the outcome measures of a new therapy would threaten the fluidity of

my research as a whole. It was on these grounds that I decided to omit the

quantitative section of my research. I do, however, intend to honour this

analysis in future research, not least because I feel it important that novel

therapies be deemed suitable for scientific enquiry more readily than is

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currently the convention. It is thought that such a move would add

worthwhile growth and development to mental health professions (Russell,

2008).

3.2 Methodological Challenges.

Having never attempted to do an IPA study before, some of the main

challenges I faced when conducting this research came when interviewing

the participants. First, because I had prior experience of exposure therapy

working unsuccessfully with a client in my own clinical practice, I wanted

to ensure that this did not influence the accounts of my participants. I was

therefore cautious of this when designing and delivering my interview

questions. I attempted to adopt an open, semi-structured style of

questioning, as suggested by Smith, Flowers and Larkin (2009) to shape the

interview to participants’ honest experiences of therapy. In addition I

frequently informed participants that I was interested in their positive and

negative experiences of exposure and Spectrum therapy.

Secondly, although I recognised the importance of recording participants’

experiences of PTSD symptoms, so that their narratives on therapy could be

put into context (see Shenton, 2004), I did not expect that some participants

would speak about their experiences of PTSD symptoms at such length.

Following the first few interviews, I began to have some concerns that the

data I was collecting was not sufficiently rich in relation to my research

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question. I raised these concerns at a supervision session and as a result

amended my interview schedule to include fewer questions on participants’

experiences of PTSD symptoms.

As a final consideration I was aware during the interview process of the

conflicting pressures I was under with regards to completing good quality

interviews whilst also working to tight deadlines. At the start of the

planning phase I hoped to transcribe each interview before completing the

next in order to help me reflect on the narratives and become immersed in

the data at an early stage. Unfortunately this goal was not attainable owing

to the time it took for ethical approval to be granted and my other university

commitments. This said I feel the quality of the data was not greatly

affected by this omission as, I did allow myself some time to reflect on the

questions asked and the information obtained.

Upon reaching the analysis phase of my research, I began to agree with my

supervisor’s warning that conducting qualitative research would be

challenging. Not only are there various ways of conducting such a piece of

research (see Smith et al., 2009: p80), but also the explorations and analyses

involve detailed and time consuming processes. Alongside this, I initially

struggled with IPAs defining feature: the double hermeneutic aspect of

interpretation where “the researcher is seen to be making sense of the

participants making sense of their world” (Smith, 2004).

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My first challenge with this concept came in the initial analysis phase, when

generating my interpretations of the data set. I was not confident in my

ability to generate meaning from the narratives of participants, to fulfil the

“interpretative aspect”, yet keep the analysis as a true representative of the

original data. Confounding my fears was the recognition that a proportion

of my interpretations centred on participant emotions. This was a concern

for me as, at the time of conducting my analysis, I was in a placement that

encouraged, and saw great value in, Emotionally-Focussed Therapy (EFT).

In addition, whilst on this placement, I was starting to recognise the value of

Dialectical Behaviour Therapy (DBT), in helping my clients recognise and

tolerate their emotions. With these contextual factors in mind I was aware

of the importance of having my supervisor continually check through my

interpretations in order to limit researcher bias and fulfil the primary aim of

IPA: to detail the lived experience of the participant (Smith et al., 2009).

3.3 Conclusion.

Undertaking such a large piece of qualitative research can be a detailed and

complicated process and I feel extremely proud that I have been able to

complete this work. There are many different ways to undertake an IPA

study and as such it often requires one to use one’s own judgement,

something that I was not particularly confident doing in the past, preferring

to seek academic guidance from tutors, and personal guidance from my

parents.

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The research has helped me to develop skills that I can transfer to my

clinical practice. I am more confident in making clinical judgements and at

expressing my clinical opinion in departmental meetings. With clients

themselves, I am more confident to apply a here and now style of working

and of making in the moment decisions. With regard to my findings

specifically, I feel these will influence the way I work with future clients

under an exposure therapy framework, not least in terms of detailing the

model, and the importance of the techniques, to my clients. I hope to

expand on the suggestions outlined for future research from this study when

I am a qualified Counselling Psychologist.

233

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5.0 APPENDICIES.

Appendix 1: Reference for the current Critical Literature

Review (Paper One)....................................................................

Appendix 2: Journal of Clinical Psychology Notes to Authors

Appendix 3: Description of Spectrum Therapy.

Appendix 4: Example of Spectrum Therapy Consent

Form...........................................................................................260

256

Appendix 5: Example Participant Consent Form.................261

Appendix 6: A copy of the research Res20 form....................262

Appendix 7: A copy of Ethical Approval.................................271

Appendix 8: Participant Information Pack............................272

Appendix 9: Debrief Sheet.........................................................274

Appendix 10: Interview Schedule..............................................276

Appendix 11: Participant Tables of Themes............................278

Appendix 12: Grand Table of Qualitative Themes...................405

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APPENDIX 1: REFERENCE FOR THE CURRENT CRITICALLITERATURE

REVIEW.

Mills, S., & Hulbert-Willaims, L. (2012). Distinguishing between

treatment efficacy and effectiveness in Post-traumatic Stress

Disorder (PTSD): Implications for contentious therapies.

Counselling Psychology Quarterly, 25 (3), 319-330.

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APPENDIX 2: JOURNAL OF CLINICAL PSYCHOLOGY NOTES TO AUTHORS.

Accessed [online:] http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1097-

4679/homepage/ForAuthors.html.

Manuscript Preparation

Format . Number all pages of the manuscript sequentially. Manuscripts should contain each of the following elements in sequence: 1) Title page 2) Abstract 3) Text 4) Acknowledgments 5) References 6) Tables 7) Figures 8) Figure Legends 9) Permissions. Start each element on a new page. Because the Journal of Clinical Psychology utilizes an anonymous peer-review process, authors' names and affiliations should appear ONLY on the title page of the manuscript. Please submit the title page as a separate document within the attachment to facilitate the anonymous peer review process.

Style . Please follow the stylistic guidelines detailed in the Publication Manual of the American Psychological Association, Sixth Edition, available from the American Psychological Association, Washington, D.C. Webster's New World Dictionary of American English, 3rd College Edition , is the accepted source for spelling. Define unusual abbreviations at the first mention in the text. The text

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should be written in a uniform style, and its contents as submitted for consideration should be deemed by the author to be final and suitable for publication.

Reference Style and EndNote . EndNote is a software product that we recommend to our journal authors to help simplify and streamline the research process. Using EndNote's bibliographic management tools, you can search bibliographic databases, build and organize your reference collection, and then instantly output your bibliography in any Wiley journal style. Download Reference Style for this Journal: If you already use EndNote, you can download the reference style for this journal. How to Order: To learn more about EndNote, or to purchase your own copy, click here . Technical Support: If you need assistance using EndNote, contact endnote@isiresearchsoft.com , or visit www.endnote.com/support .

Title Page . The title page should contain the complete title of the manuscript, names and affiliations of all authors, institution(s) at which the work was performed, and name, address (including e-mail address), telephone and telefax numbers of the author responsible for correspondence. Authors should also provide a short title of not more than 45 characters (including spaces), and five to ten key words, that will highlight the subject matter of the article. Please submit the title page as a separate document within the attachment to facilitate the anonymous peer review process.

Abstract . Abstracts are required for research articles, review articles, brief reports, commentaries, and notes from the field. Abstracts must be 120 words or less, and should be intelligible without reference to the text.

Permissions . Reproduction of an unaltered figure, table, or block of text from any non-federal government publication requires permission from the copyright holder. All direct quotations should have a source and page citation. Acknowledgment of source material cannot substitute for written permission. It is the author's responsibility to obtain such written permission from the owner of the rights to this material.

Final Revised Manuscript . A final version of your accepted manuscript should be submitted electronically, using the instructions for electronic submission detailed above.

Artwork Files . Figures should be provided in separate high-resolution EPS or TIFF files and should not be embedded in a Word document for best quality reproduction in the printed publication. Journal quality reproduction will require gray scale and color files at resolutions yielding approximately 300 ppi. Bitmapped line art should be submitted at resolutions yielding 600-1200 ppi. These resolutions refer to the output size of the file; if you anticipate that your images will be enlarged or reduced, resolutions should be adjusted accordingly. All print reproduction requires files for full-color images to be in a CMYK color space. If possible, ICC or ColorSync profiles of your output device should accompany all

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digital image submissions. All illustration files should be in TIFF or EPS (with preview) formats. Do not submit native application formats.

Software and Format . Microsoft Word is preferred, although manuscripts prepared with any other microcomputer word processor are acceptable. Refrain from complex formatting; the Publisher will style your manuscript according to the journal design specifications. Do not use desktop publishing software such as PageMaker or Quark XPress. If you prepared your manuscript with one of these programs, export the text to a word processing format. Please make sure your word processing program's "fast save" feature is turned off. Please do not deliver files that contain hidden text: for example, do not use your word processor's automated features to create footnotes or reference lists.

Article Types

Research Articles . Research articles may include quantitative or qualitative investigations, or single-case research. They should contain Introduction, Methods, Results, Discussion, and Conclusion sections conforming to standard scientific reporting style (where appropriate, Results and Discussion may be combined).

Review Articles . Review articles should focus on the clinical implications of theoretical perspectives, diagnostic approaches, or innovative strategies for assessment or treatment. Articles should provide a critical review and interpretation of the literature. Although subdivisions (e.g., introduction, methods, results) are not required, the text should flow smoothly, and be divided logically by topical headings.

Brief Reports . Abbreviated reports will be considered, and are especially encouraged if they involve: 1) replications; 2) replication failures; 3) well-designed clinical trials and other studies with negative findings; 4) potentially interesting serendipitous findings or results obtained by post-hoc hypotheses; or 5) Dissertations in Brief (DIB). DIB is intended to encourage students to submit innovative research conducted during the student’s graduate studies. It is expected that DIB manuscripts would be submitted by the student, who would be the first author. All Brief Reports should contain an abstract and provide a concise synopsis (12 manuscript pages or less) of the major findings presented in the study. The format of manuscripts submitted for Brief Reports may adhere to the Research Report or Review Article format as appropriate. Authors of Brief Reports should make available a full description of method and statistical analyses with a report of all data and information needed for meta analyses. Brief Reports should include explicit statements of limitation, and power analyses may be necessary.

Commentaries . Occasionally, the editor will invite one or more individuals to write a commentary on a research report.

Editorials . Unsolicited editorials are also considered for publication.

Notes From the Field . Notes From the Field offers a forum for brief descriptions of advances in clinical training; innovative treatment methods or community based initiatives; developments in service delivery; or the presentation of data from research projects which have progressed to a point

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where preliminary observations should be disseminated (e.g., pilot studies, significant findings in need of replication). Articles submitted for this section should be limited to a maximum of 10 manuscript pages, and contain logical topical subheadings.

News and Notes . This section offers a vehicle for readers to stay abreast of major awards, grants, training initiatives; research projects; and conferences in clinical psychology. Items for this section should be summarized in 200 words or less. The Editors reserve the right to determine which News and Notes submissions are appropriate for inclusion in the journal.

Editorial Policy

Manuscripts for consideration by the Journal of Clinical Psychology must be submitted solely to this journal, and may not have been published in another publication of any type, professional or lay. This policy covers both duplicate and fragmented (piecemeal) publication. Although, on occasion it may be appropriate to publish several reports referring to the same data base, authors should inform the editors at the time of submission about all previously published or submitted reports stemming from the data set, so that the editors can judge if the article represents a new contribution. If the article is accepted for publication in the journal, the article must include a citation to all reports using the same data and methods or the same sample. Upon acceptance of a manuscript for publication, the corresponding author will be required to sign an agreement transferring copyright to the Publisher; copies of the Copyright Transfer form are available from the editorial office. All accepted manuscripts become the property of the Publisher. No material published in the journal may be reproduced or published elsewhere without written permission from the Publisher, who reserves copyright.

Any possible conflict of interest, financial or otherwise, related to the submitted work must be clearly indicated in the manuscript and in a cover letter accompanying the submission. Research performed on human participants must be accompanied by a statement of compliance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) and the standards established by the author's Institutional Review Board and granting agency. Informed consent statements, if applicable, should be included with the manuscript stating that informed consent was obtained from the research participants after the nature of the experimental procedures was explained.

The Journal of Clinical Psychology requires that all identifying details regarding the client(s)/patient(s), including, but not limited to name, age, race, occupation, and place of residence be altered to prevent recognition. By signing the Copyright Transfer Agreement, you acknowledge that you have altered all identifying details or obtained all necessary written releases.

All statements in, or omissions from, published manuscripts are the responsibility of authors, who will be asked to review proofs prior to publication. No page charges will be levied against authors or their institutions for publication in the

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journal. Authors should retain copies of their manuscripts; the journal will not be responsible for loss of manuscripts at any time.

APPENDIX 3: DESCRIPTION OF SPECTRUM THERAPY.

Spectrum Therapy is an emotion focused therapy for Posttraumatic Stress

Disorder that utilises cognitive restructuring techniques to help reframe past

problematic memories into positive resourceful strategies that the clients can

use in the present day.

The first step in the therapeutic protocol involves some relaxation

techniques. This usually involves muscle relaxation and encourages clients

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to identify a “safe place” within their minds that they can go to if they are

finding the protocols distressing. Clients are asked to hold in mind the

memory that they found traumatic before identifying the associated

emotions attached to the memory. Once an emotion has been identified

clients are asked to describe the emotion in terms of a colour or a sensation

and to follow that sensation or colour back to the first time they experienced

the emotion (this usually takes the client back to childhood). Once the

client has identified this memory they are asked to notice what cognitive

associations they made in relation to the target emotion. Throughout this

process, clients are reminded that they can “go” to their safe place if they

are finding anything too distressing. Clients are required to tell the

therapist the colour/sensation and the cognitive associations related to the

emotion but not the details of the traumatic event itself. Whilst clients are

still holding the past memory in mind, they are asked to identify any

learning that they could take from the event that perhaps they didn’t see

before when they were a child. Once a positive learning has been identified,

clients are encouraged to attach a colour or sensation to this new learning

and to mentally replace this with the old colour/sensation attached to the

emotion originally identified. This whole process is repeated with each

individual emotion that a client relates to the traumatic event.

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APPENDIX 4: EXAMPLE OF SPECTRUM THERAPY CONSENT FORM.

RESEARCHER: SarahMills University of Wolverhampton

sarah..mills@wlv.ac.uk Millennium City Building

SUPERVISOR: Dr Lee Hulbert-Williams Wolverhampton

lee@wlv.ac.uk WV1 1SB

[Consent Form – Spectrum Therapy]

STUDY TITLE: How do veterans make sense of their disengagement from traditional exposure therapy and their subsequent

265

engagement in a non-exposure based intervention for PTSD?

The founder of Spectrum Therapy hereby gives consent for the named researcher to carry out a study investigating client experiences of our post-traumatic stress disorder intervention.

I understand the nature of the study and am willing to volunteer participants for the purpose of this research investigation.

I give consent for Spectrum Therapy and it’s interventions to be documented in this research project.

I am aware of participant’s confidentiality rights and their right to withdraw from the study at any time.

Signed………………………………….. Date……………………

Name (in print)………………………………….

Position in the charity………………………………………….

REF: CONSENT FORM: ST

APPENDIX 5: EXAMPLE PARTICIPANT CONSENT FORM.

RESEARCHER: Sarah Mills University of Wolverhampton

sarah..mills@wlv.ac.uk Millennium City Building

SUPERVISOR: Dr Lee Hulbert-Williams Wolverhampton

lee@wlv.ac.uk WV1 1SB

Tel: 01902 321174

[Consent Form – Section 2]

266

STUDY TITLE: How do veterans make sense of their disengagement from traditional exposure therapy and their subsequent engagement in a non-exposure based intervention for PTSD?

I have read and understood the attached information sheet regarding the doctoral study which is looking to investigate client preferences for combat-related PTSD treatments.

I am aware that the study will require me to answer questions regarding PTSD and the subsequent treatment methods I have had to eradicate my symptoms of the disorder.

I have been informed of my confidentiality rights and my right to withdraw from the study at any time.

I am aware that if I have any queries regarding the current study that I should contact the researcher or supervisor on the details provided above.

I hereby consent to taking part in the study.

Signed………………………………….. Date……………………

I would like to receive a summary of the research findings

by email……………………………………………………………………………..

or by by post……………………………………………………………………………..

APPENDIX 6: A COPY OF THE RESEARCH RES20 FORM.

RES 20B

School of Applied Sciences Behavioural Sciences Ethics Committee: submission of project for approval

This form must be word processed – no handwritten forms can be considered ALL sections of this form must be completed No project may commence without authorisation from the School Ethics

Committee

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To be completed by SEC :

Date Received:

Project No:

CATEGORY B PROJECTS:

There is identifiable risk to the participant’s wellbeing, such as:

• significant physical intervention or physical stress. • use of research materials which may bring about a degree of psychological stress or upset.• use of instruments or tests involving sensitive issues.• participants are recruited from vulnerable populations, such as those with a recognised clinical or psychological or similar condition. Vulnerability is partly determined in relation to the methods and content of the research project as well as an a priori assessment.

All Category B projects are assessed first at subcommittee level and once approved are forwarded to the School Ethics Committee for individual consideration. Undergraduates are not permitted to carry out Category B projects.

Title of Project: How do veterans make sense of their disengagement from

traditional exposure therapy and their engagement in a non-

exposure based intervention for PTSD?

Name of Supervisor:

(for all student projects)

Dr Lee Hulbert-Williams

Name of Investigator(s): Miss Sarah Mills

Level of Research:

(Module code, MPhil/PhD, Staff)

Practitioner Doctorate in Counselling Psychology.

Qualifications/Expertise of the

investigator relevant to the

submission:

Bsc Honours Degree in Psychology.

Practitioner Doctorate in Counselling Psychology: relevant

modules covered: Cognitive-Behavioural Therapy for PTSD,

Research methods and Advanced Research method modules.

Participants: Please indicate the

population and number of

participants, the nature of the

participant group and how they will be

Approximately 5 participants will be recruited for the study. All

participants will have been treated for post-traumatic stress

disorder through both exposure therapy and the non-exposure

intervention; Spectrum Therapy. All participants will be

combat veterans varying in age from 18-60 years old.

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recruited.

Continued overleaf

Please attach the following and tick the box provided to confirm that each has been included:

Rationale for and expected outcomes of the study

Details of method: materials, design and procedure

Information sheet* and informed consent form for participants

*to include appropriate safeguards for confidentiality and anonymity

Details of how information will be held and disposed of

Details of if/how results will be fed back to participants

Letters requesting, or granting, consent from any collaborating institutions

Letters requesting, or granting, consent from head teacher or parents or equivalent, if

participants are under the age of 16

Is ethical approval required from any external body? YES/NO (delete as appropriate)

If yes, which Committee?

NB. Where another ethics committee is involved, the research cannot be carried out until approval has been

granted by both the School committee and the external committee.

Signed: Date:

(Investigator)

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Signed: Date:

(Supervisor)

Except in the case of staff research, all correspondence will be conducted through the supervisor.

FOR USE BY THE SCHOOL ETHICS COMMITTEE

Divisional Approval Granted:

_________________________________

(Chair of Behav Sci Ethics Committee)

Date:

School Approval Granted:

Date

(Chair of School Ethics Committee)

Rationale for the study.

Post-traumatic stress disorder (PTSD) was recognised by the Diagnostic and

Statistics Manual (DSM-IV) as a standalone disorder in 1980 (Power,

2002). The life time prevalence of the disorder is thought to be between 1-

14%, with even higher rates recorded for specific populations such as war

veterans or rape victims (Zayfert & Becker, 2007).

270

Combat is among the list of life experiences associated with symptoms of

PTSD. Accurate diagnosis of combat-related PTSD can often be

complicated by the existence of concurrent disorders including depression,

anxiety and substance abuse (Frueh, Turner and Beidel, 1995). War related

nightmares, paranoia, flashbacks and persistent hyper arousal states are

common symptoms associated with combat, decades after military service

(Richard & Lauterbach, 2006). Alongside this, researchers are starting to

highlight symptoms specific to this trauma group such as shame, guilt and

moral injury (Litz et al., 2009). Life time prevalence of the disorder has

been estimated to be between 15-20% for those exposed to combat (Frueh

and Hamner, 2000) and as such it is important that researchers aim to find

an effective treatment method for the disorder in this population.

It is clear from the literature reviewed that a good deal of research work has

been done in exploring the efficacy of exposure therapy in the treatment of

PTSD since its introduction into the DSM-IV. Most of the research in this

area supports the use of exposure therapy in treating this disorder however it

has been highlighted that this form of therapy may not be suitable for all

sufferers (Bradley et al., 2005). Recent work aims to explore non-exposure

therapies amidst concerns that exposure therapy is less suitable for combat

veterans with PTSD on the grounds of dropout (Erbes, Curry & Leskela,

2009). It is also suggested that research may benefit from the exploration of

client preferences for treatment (Frueh et al., 2002). It is argued that this

mode of exploration could help us mould current methods of treatments

271

around their usefulness to clients and help us move away from what some

researchers’ term “the rigid boundaries of exposure based techniques”

(Feeney, Hembree & Zoellner, 2003).

The current study aims to address this gap in the PTSD literature by

qualitatively examining client preferences for a non-exposure based

treatment method called Spectrum Therapy which is currently offered to

combat veterans through UK charities and through web advertising. The

majority of clients who receive this treatment have experienced some form

of exposure therapy in the past which hasn’t worked for them. It is

therefore important that the study looks to investigate client experiences of

past exposure therapy and their current experiences of the alternative non-

exposure based treatment method. This will help research move into the

domain of process outcome, something which Freuh et al (2002) highlights

as an area which needs more attention in PTSD research.

Expected outcomes of the study.

The current study is of particular relevance to counselling psychology

research as it aims to assess a non-exposure based treatment method for

PTSD through the subjective experiences of clients exposed to this

treatment intervention. More generally, it is hoped that the outcomes of this

study will help further our understanding of effective, non-exposure based

treatment interventions for PTSD.

272

Method.

Frueh et al (2002) have highlighted a need for researchers to evaluate

process outcomes in PTSD treatment. They suggest that studies may need

to look at patient satisfaction in the treatment of PTSD to help guide future

research.

Participants will be recruited for the study through their involvement with

Spectrum Therapy. The participants will have already completed the therapy

carried out by the charity and will also have had prior experience of an

exposure based intervention. They will be asked a series of specialist

questions designed by the researcher which ask them about their

experiences of treatment. This information will be qualitatively analysed to

help identify what the participants feel either helped or hindered their

engagement in treatment. This client led information could then help guide

future research which looks to find the most effective forms of treatment for

combat-related PTSD.

In order to gauge the usefulness of this alternative type of therapy,

participants will be asked to answer a series of questions to determine their

preference of treatment. It will be interesting to explore what worked or

didn’t work for them in this type of treatment. What was different between

this type of treatment and the treatment they have received in the past?

273

What their preference is for treatment and which treatment method was

most effective and why?

Data Analysis.

All questions will be designed by the researcher in a semi-structured format

to allow for flexibility.

The questions will be delivered by the researcher in a face to face interview.

It is proposed that the qualitative data will be analysed using Interpretive

Phenomenological Analysis (IPA). This form of analysis will enable

recurrent themes to be identified from the specific data set and be discussed

in terms of the usefulness of therapy and participant preferences of combat-

related PTSD treatment.

Data Management.

All data will be anonymous. At the top of each interview schedule,

participants will be asked to write a sequence of letters or numbers that is

individual and memorable to them. This will help maintain participant

confidentiality whilst allowing for their answers to be pulled from the study

if required.

274

The data collected for the current study will be stored securely for five years

after publication after which it will be destroyed.

Ethical Issues.

All participants will be given an information pack. This will contain

information on the nature of the study, the confidentiality policy, their right

to withdraw and their consent form. Participants will be asked to read all

documents before filling in their consent forms.

Due to the fact that the interviews may require participants to revisit events

relating to their PTSD, it is important that clients feel comfortable in not

consenting to take part in the study if they so wish. These forms will

therefore be administered by the charity two weeks before the interview

date. Client’s who do consent to the study will be reminded of their right to

withdraw both during the interview and after the interview if they decided

they do not want their answers to be documented.

Participants who wish to receive a summary of the findings, on completion of the

study, will be asked to provide the appropriate mailing details on the consent

form.

275

The founder of Spectrum Therapy is fully aware of the nature of this study

and is supportive in volunteering all participants for its purpose. He is

aware that his therapeutic intervention will be documented in the study. A

written and signed consent form will be obtained from the charity after the

proposal has been ethically approved.

The proposal for the current study will be assessed by the University’s

ethics committee. Prior to the recruitment of participants, permission from

the ethics board will have been granted. No NHS approval is needed for

this study.

APPENDIX 7: A COPY OF THE ETHICAL APPROAVAL.

School Ethics Committee

Minutes of the School Ethics Committee held at 10.00am on Wednesday 22nd June 2011 in MC123.

Present

Dr N Morris Chair

Prof K Manktelow

276

Dr Ken Scott (New Cross)

Dr. Iain Coleman

Dr Yvette Primrose

Mrs Mandeep Sarai Minute Secretary

1. Apologies

Apologies were received from Prof R Morgan

2. Minutes of previous meeting

The minutes were accepted as an accurate record.

3. Matters arising from previous minutes

IPLC

5. Chairs Action

4. Sarah Mills

This form has been passed.

APPENDIX 8: INFORMATION PACK FOR PARTICIPANTS.

RESEARCHER: Sarah Mills University of Wolverhampton

sarah..mills@wlv.ac.uk Millennium City Building

SUPERVISOR: Dr Lee Hulbert-Williams Wolverhampton

lee@wlv.ac.uk WV1 1SB

277

[Information Sheet – Section 2]

Information sheet regarding the current study:

Aim: To investigate client experiences of PTSD treatment. Experiences from Spectrum Therapy and past exposure treatments will be discussed in terms of their effectiveness and likeability.

STUDY TITLE: How do veterans make sense of their disengagement from traditional exposure therapy and their subsequent engagement in a non-exposure based intervention for PTSD?: An Interpretative Phenomenological Analysis.

Dear …………..…..

I am currently undertaking my doctoral training in Counselling Psychology, and as part of my research project I am carrying out a study to investigate effective treatment methods for combat-related PTSD. For this, I am going to be investigating a non-exposure based intervention in treating PTSD symptoms called Spectrum Therapy.

The aim of the study is to investigate client preferences for combat-related PTSD treatment. In order to do this, I am inviting people who have had both previous experiences of Spectrum Therapy and experiences of the more commonly used exposure therapy delivered through the NHS or Combat Stress.

The aim is to have a 30-60 minute interview with the individuals willing to partake in the study to determine their preferences for, and experiences of, past interventions used to help treat their combat-related PTSD symptoms. All questions will be designed by the researcher and delivered through an interview.

Your rights as a participant.

Provision will be made to protect the rights and well-being of the participants by adhering to the relevant ethical guidelines and code of conduct (BPS, 2006; Division of CP, 2001; HPC, 2008); and Data Protection Act (1998).

278

Confidentiality: All data collected for the purpose of the study will be kept confidential. Your name will not be added to any material used in the interviews. Instead we would ask you to note down a unique sequence of letters or numbers that only you know on the top of your interview schedule at the end of the session. This will enable recognition of your answers if you decide you want to withdraw from the study.

The data provided will be stored in a secure unit and destroyed 5 years after the research has been examined by the University Board at Wolverhampton.

The right to withdraw: As a participant you are free to withdraw at any time during the study without giving any reason and without prejudice. If you wish to withdraw from the study, all information and data collected from you (interview transcript and consent form) will be destroyed, or it can be returned to you if requested. However, once the analysis has been completed, it will be difficult to remove the information from the report, which remains anonymous as explained above.

Thank you for taking the time to read this. If you wish to take part in this study please can you sign and date the consent form attached.

If you require any further information or clarification on any of the points listed above please feel free to e-mail the researcher on the e-mail address detailed above.

Yours sincerely

Researcher: Sarah Mills

Supervisor: Dr Lee Hulbert-Williams

APPENDIX 9: DEBRIEFING FORM.

School of Applied Sciences

University of Wolverhampton

City Campus - South Wulfruna Street Wolverhampton WV1 1LY

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Debriefing Document Many thanks for participating in the interview; your views are greatly appreciated.

This research project is designed to explore client preferences for combat-related PTSD treatment. The study looks at client reasons for their disengagement from traditional exposure therapy; as delivered through the National Health Service, and their subsequent engagement in Spectrum Therapy

Please remember that although some of the information from this research may be published, your confidentiality will be secured and you will not be identifiable. The tape from the interview will be kept in a locked cabinet and given a number which is known only to the researcher. Following transcription the tapes will be destroyed. Any identifiable information or names will be removed from the transcripts to protect your identity.

You also have the right to withdraw from the research at any point and with no consequences.

A general summary of the findings of the study can be obtained by sending an email to the researcher on the below email address from autumn 2011. Unfortunately no individual feedback can be given.

Following the debriefing, if you require any more help please find below the numbers and web addresses of some organisations in your area which may be able to help with any issues that may arise.

Samaritans: 08457 90 90 90 (24hrs).

Veterans UKtel: 0800 1692277web: www.veterans-uk.info/Provides free help and advice to both military personnel and the veterans community

ASSIST (Assistance Support and Self Help in Surviving Trauma)helpline: 01788 560 800web: www.assisttraumacare.org.uk Support, understanding and therapy for people experiencing PTSD, and families and carers

The Human Givens Instituteweb: www.hgi.org.uk

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Provides a list of therapists who use guided imagery and the ‘rewind’ technique

Thank you once again for your participation.

Sarah Mills. sarah.mills@wlv.ac.uk Psychology Department Wolverhampton University Wulfruna Street Wolverhampton WV1

E-mail: sarah.mills@wlv.ac.uk

APPENDIX 10: A COPY OF THE INTERVIEW SCHEDULE.

The proposed topics for discussion are as follows:

Pre – treatment questions .

1. What was life like for you with PTSD?

2. Symptomatology

3. Effect on families and work life.

Their experience of exposure therapy.

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1. What type of therapy have they received in the past to help with their

PTSD?

2. How long were they in therapy for?

3. What influenced their decision to disengage from the therapy?

4. What specifically did they find difficult or un-helpful, if anything?

5. How did they feel about the therapeutic protocols/what they were

asked to do in therapy?

6. How comfortable did they feel in the sessions?

7. Did they find anything about the therapy helpful?

8. The overall experience.

9. Would you consider this mode of therapy in the future if you needed

it?

10. If not, why not?

Their experience of Spectrum Therapy

1. What made you decide to look for an alternative treatment method?

2. Why Spectrum Therapy?

3. What was it about this type of therapy that appealed to you?

4. How long were they in therapy for?

5. What was it about the therapeutic method that influenced their

decisions to stay engaged in the treatment?

6. What specifically did they find difficult or un-helpful, if anything?

7. How did they feel about the therapeutic protocols/what they were

being asked to do in therapy?

8. How comfortable did they feel in the sessions?

9. Did they find anything about the therapy helpful?

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10. The overall experience.

11. Would you consider this mode of therapy in the future if you needed

it?

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